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�► 1pt ppYMEN� <br /> LVED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTI�I DEPARTnZENT MAY 2 3 2 13 <br /> MASTERFILE RECORD INFORMATION FORIH <br /> N JOAOUI1I COUNTY <br /> ❑New EH Program at ExistingFacility New EH Program and Neiv Facility S1 ENVIRO NTAL <br /> Facility - ��oZ ) ` g Pro ram Record ID a �7 HEALTH pERARTMENT <br /> Facility Address + �r�L ( A °I53'71v <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1604) <br /> ❑Restaurant: Seating Capacity Square Footage Food handlers Course required:- Yrs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines—Number of Units <br /> ❑Retail Market—Square footage ❑with Meat Market only ❑ MuItiple Departments ❑ Prepackaged Goods Only <br /> ElMobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event --Dates of operation from to ❑Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS INVASTE PROGRAM(2200) <br /> ❑hazardous Waste Generator.--- Tons Generated Per Year ❑Recycle f Exempt System(2299) <br /> ❑CRT Offsite Handlers(221 s) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pemnit-By Rule Fined Unit ❑Permit-By-Rule Household Hazardous Waste <br /> ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> .UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and R forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee HousinKabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑Environmental Assessment El UST-CAP Site L7 Local HW Cleanup Site. ❑NPLISEP Cleanup Site El UIC Site <br /> ❑Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑RNVQCB Cleanup Site ❑`Vater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑P9ol ❑ Spa 1.3 Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑Poultry Farah Maximum number of birds ❑Kennel <br /> TATTOO,BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> Tattooing(41k1)t ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle-# <br /> ❑ Pumper Yard ❑Package Treatment Plant ❑Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag I Cannery Waste Site ❑Studge/Asir Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑Process[Recycle Facility ❑CIA-Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--[] 2-10 ❑ 11-60---❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use Pff'SFIM-M-02-403 .Glue Application Foml <br /> EMERGENCY NOTIFICATION FOR TIM FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGBAM ELEN1FNT FEE ) ❑Surcharge FEE - ❑ Other FEE <br /> INSPECTOR#�. � 5�.4i� PERMIT VALiD ? 3 to��3'�l 11 Food Handler_ <br /> ❑ Chcck f`- AMOUNT PAW `� «*� — gate 114VOICE# -- <br /> C ash R_EviFWFD BY QC �3 ALCOUN—f ING`OFFICE <br /> Dat <br />