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SAN JOAQUIN COUNTY RONMENTAL HEALTH DEPARTIA ENT MASTERFILE RECORD-INFORMATION FORM RECEIVED ❑New EH Pro I gram at Existing FaclIq ❑New EllProgram and New Facility JAN 2 7 ZO 12 Facilif ID Pro ra m Record ID 3 Facility Address � o'31-62-w- A& � '�r"^t } 'u rZ-ENVIRONMENTAL HEALTH (Please Check the appropriate description and specify gZ number of units and pertinent information.) PERMIT/SERVICES FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YEs❑ No❑ ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines Number of Units ❑Retail Market----Square footage ❑with Meat Market only ❑Multiple Departments ❑Prepackaged Goods Only ❑Mobile Food Vehicle-----Make Vehicle Type Color Registration# License# Sticker# ❑Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# ❑Temporary Food Facility----.Dates of operation from to 11 let Plant ❑Special Event —Dates of operation from to ❑Produce Stand DAIRY PROGRAM(200 ) ❑Grade A Dairy ❑Grade B Dairy ❑Milk Dispenser---Number of Containers in Multi-Head Unit CUPA ❑State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) I ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle I Exempt System(2299) ❑CRT Offsite Handlers(2218) ❑Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑Conditionally Exempt(CE) L7 Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USIA and B forms HOUSING PROGRAM(2400) ❑Hotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units Employee Housing(2700)Use Employee MousingAW or Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) 11 Environmental Assessment (3UST-CAPSite El Local HW Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site ❑Abandoned HW Site ❑non-NPUSEP Cleanup Site ❑RWQCB Cleanup Site 1❑Water Quality Remediation Site- RECREATIONAL iteRECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility. ❑P901 ❑Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area VECTOR.CONTROL PROGRAM(4000) ❑Poultry Farm Maximum number of birds ❑Kenner ATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) Tattooing(4121) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) CI Pumper Vehicle Registration# License# Capacity Vehicle# ❑Pumper Yard ❑Package Treatment Plant- ❑Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑Sludge/Ask Site ❑Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑CIAiLandfill Site ❑Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd Number of Units ❑Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) Q Primary Care ❑Acute Care ❑Skilled Nursing ❑Large Generator D Small Generator ❑Limited Hauler ❑Transfer Station ❑Veterinary Clinic ❑Common Storage Facility-0 2-10 ❑ 11-60------(]>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PHS EMD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THis FACILITY ANDIOR PROGRAM CONTACT PERSONN Day Ph Night P -I PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# 7J PERMIT VALID . to ❑Food Handier ❑ Check# AMOUNT PAID Date INVOICE# Cl Cash REViEwED BY ACCOUNTING OFFICE Date Z 13 Z1:9_11 — ,— Macte fi a Record Pink