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U <br />0 <br />SAN JOA.QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECO" INFORMATION FORM <br />❑ New EH Prol;Tam at Existing Facility _ Do New EH Program and New Facility <br />I Facility ID Oa�Dd ,�J 1 i Program Record ID <br />32 � W Ammer iGn4 51d� ",-CA-,W2,09 <br />G <br />MAR 2 3 2012 <br />ENVIRONMENT HU "' 1 <br />PERMIT/SERVICE <br />P aCHILY Address _: <br />(Please Check the appropriate description and specify size, number of units and pertinent information) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YEs ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines -= umber of Units <br />❑ Retail Market ---Square footage ❑ with Meat Market only ❑ Multiple Depart is ❑ Prepackaged Goods Only <br />11Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />11Mobile Food Prep Unit -Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Temporary Food Facility—Dates of operation from to <br />❑ Special Event -Dates of operation from o <br />DAIRY PROGRAM (2000 <br />❑ Ice Plant <br />❑ Produce Stand <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ penser Number of Containers in Multi -Bead Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) i <br />❑ Hazardous Waste Generator. - Tons Generat Per Year ❑ Recycle I Eiempt System (2299) <br />❑ CRT Offsite Handlers (2218) ❑ l r ly (2222) _ ❑ Appliance Reeyclers (2217) <br />Tiered Permitting Facility ❑ a nally Authorized (CA) Cl Conditionally Exempt (CE) <br />❑ ABOVEGROUND STORAGE TANK FACT% <br />UNDERGROUND STORAGE TANK ST) <br />HOUSING PROGRAM (2400) 7 <br />[IHotel/Motel Number of Units <br />Employee Housing (2700) Use Fin Io e o bor <br />SITE MITIGATION (2900) <br />❑ Environmental Assessment ❑ UST- Site <br />❑ Abandoned 11W Site ❑ no SEP <br />RECREATIONAL HEALTH PROGRA (3600) <br />Number of Pools/Spas at Facility . I ❑ P901 <br />VECTOR.CONTROL PROGRAM) <br />❑ Poultry Farm Maximum mber of birds <br />0 Tattooing (4121) <br />lay Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous NY aste <br />(2390) Number of AST <br />1(2300) Use UST A and B forms <br />.❑ Jail or Exempt Institution Number of Units <br />Form <br />UNDERGROUND INJECTION CONTROL -0000) <br />❑ Local 11W Cleanup Site. ❑ NPLISEP Cleanup Site ❑ UIC Site <br />Cleanup Site ❑ RWQCB Cleanup Site - ❑ `rater Quality Remediation Site <br />❑ Spa <br />❑ Body Piercing (4120) <br />❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />(4100) <br />❑ Permanent Cosmetics (4122) <br />❑ Pumper Vehicle -Regi tion # License # Capacity Vehicle# <br />❑ Pumper Yard ❑ Package Treatment Plant- ❑ Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station 11 Ag / Cannery%N aste Site [1 Studge/Asii 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/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care El Acute Care ❑ Skilled Nursing 11 Large Generator 0 Small Generator ❑Limited hauler <br />® Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility --11 2 - 10 ❑ 11- 60 --❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PIYSFffD f6-02-003 BtrreApplica[ion Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br />CONTACT iERSON- EGA V.t tL11 Day Ph i�� 1-7-1 Night Ph 209 <br />PROGRRAMELEMEt`IT FEE / ❑ Surcharge FEE - ❑ Otber FEE _ <br />INSPECTOR# _i PERMITVALID to ❑ Food handler_ <br />11 Check 9 AATOUNT P e ID - �/' _ Date INVOICE # —_-- El Cash Cash REVIEWED BY AccouNTiw-,OFFICE _ �—� Date 3 �— <br />