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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTIOMEENT <br />MASTERFILE RECORD INFORMATION FORM <br />E]New EH Program at Existing Facility L` -flew EH Program and New Facility_ <br />Facility Address 2-.309 5 A%S F Sr, 'TkACV Cly `i5� ` <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD P OGRAM (1600) <br />g Restaurant: Seating Capacity SquareFootage Food Handlers Course required: YES 0 No `� <br />ElCommissary E]Dry storage only ith Food Preparation E ending Machines Number of Units <br />Retall Market—Square footage u` ith Meat Market only ElMultiple Departments F „ Prepackaged Goods Only <br />tl Mobile Food Vehicle -Make Vehicle Type Color <br />Registration # License # Sticker # <br />Mobile Food Prep Unit Make Vehicle Type Color <br />ti <br />Registration # License # Sticker # <br />OTemporary Food Facility -Dates of operation from to nl Ice Plant <br />`� pecial Event Dates of operation from to �` Produce Stand <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 1013rade B Dairy Milk Dispenser -Number of Containers in Multi -Head Unit <br />COPA State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />Hazardous Waste Generator Tons Generated Per Year ORecycle/Exempt System (2299) <br />F9CRT Offsite Handlers (2218) —E]Silver Only (2222) Appliance Recyclers (2217) <br />Tiered Permitting Facility --------------- :I Conditionally Authorized (CA) M Conditionally Exempt (CE) <br />[Elpermit-By-Rule Fixed Unit ° Permit -By -Rule Household Hazardous Waste <br />BOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use USTA and B forms <br />HOUSING PROGRAM (2400) <br />Hotel/Motel —Number of Units Tail or Exempt Institution ---Number of Units <br />Employee Housing (2700) Use Employee HousinWLabor Camp AppllCatiOn Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTRO6 (3000) <br />Environmental Assessment DUST -CAP Site Local HW Cleanup Site ' I NPUSEP Cleanup Site I° UIC Site <br />Ei bandoned HW Site =1 non-NPUSEP Cleanup Site ff]RWQCB Cleanup Site Mater Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility WPool [91Spa <br />VECTOR CONTROL PROGRAM (4000) <br />U Poultry Farm Maximum number of birds <br />Mout of Service Pool/Spa SNatural Bathing Area <br />:r Kennel <br />TATTOO, BODY PIERCING PERMANENT COSME ROGRAM (4100) <br />attooing (4114 ody Piercing (4120)of Permanent Cosmetics (4122) <br />LI UID WASTE PROGRAM (4200) <br />F Pumper VehicleRegistration # License # Capacity Vehicle # <br />OPumper Yard �`�i Package Treatment Plant —Chemical Toilets —Number of Units <br />SOLID WASTE PROGRAM (4400) <br />LJ -Landfill LL ransfer Station t' Ag/Cannery Waste Site ludge/Ash Site <br />rl aste Tire Facility SCompost Facility OProceSS/Recycle Facility OCIA Landfill Site <br />ERefuse Vehicles t# of Units) P Dumpsters > 20 cu yd (# of units) Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care " `' !� �� « <br />—Acute Care [OSkilled Nursing Large Generator .Small Generator •� Limited Hauler <br />OTransfer Station ElVeterinary Clinic ECommon Storage Facility a" - 10 Ell1 -60 Eb 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON Day Ph F, LO - Night Ph <br />PROGRAM ELEMENT 400 FEE l OSurcha e FEE :i Other FEE <br />INSPECTOR # U_QQ PERMIT VALID to • v Ei Food Handler <br />Check # AMOUNT PAID iL Date INVOICE# O 7,6 S- <br />�I Kash REVIEWED BY �l„t �,R (� -- ACCOUNTING OFFICE Date <br />48-02.034 MASTERFILE RECORD INFORMATION PINK <br />11115/07 <br />