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SAN i-OAQUIN COUNTY E ONMENTAL HEALTH DEPART T RECEIVED <br /> MASTERFILE RECORD-INFORMATION FORM <br /> ❑New EH Pro am at Existing Facility ❑New EH Program and NewwFacility JAN 2 7 2W <br /> Facility ID ;•C�`' Pro ram Record ID `7 <br /> 12e7EWAL <br /> Facility Address ��L3(. � - � C ' �� ENViON <br /> pRERMIT SERVICESLTH <br /> {Please Check the appropriate description and specify s___,e. number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course quired:. YEs 11 NO <br /> re ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines Number of Units <br /> ❑Retail Market----Square footage ❑with Meat Market only ❑Multiple Departments ❑Prepackaged Goods Only <br /> ❑ Mobile 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 ❑Miik Dispenser---Number of Containers in Multi-Head Unit <br /> CUPA ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) t <br /> ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2219) ❑Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility--------- ❑Conditionally Authorized(CA) ❑Conditionally Exempt(CE) <br /> ❑Permit-By Rule Fixed 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 B forms <br /> HOUSING PROGRAM(2400) <br /> ❑Hotel/Motel Number of Units -❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned MY Site Elnon-NPLISEP Cleanup Site [I �RNYQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility,. ❑P901 ❑Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR.CONTROL PROGRAM(4000) <br /> [3Poultry Farm Maximum number of birds 11 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> [ITattooing(4121) Ef Body Piercing(4120) [1 Permanent Cosmetics(412 2) <br /> LIQUID WASTE PROGRAM(4200) <br /> 13 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/Cannery Waste Site ❑Sludge/Ash 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 ' ❑Acute Care ❑Skilled'Nursing ❑Large Generator 0 Small Generator ❑Limited hauler <br /> ❑Transfer Station ❑Veterinary Clinic ❑Common Storage Facility---O 2-10 ❑ 11-60-----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 McApplicatiatt Form <br /> EMERGENCY NOTIFICATION FOR Tins FACILITY AND/OR PROGRAM <br /> CONTACT PERSON« '-��r-1 i�Qr• Day Ph 2� f��7- �gj Night Ph L�9 Z' � <br /> PROGRAM ELEMENT 141�0 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID to ❑Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REvIEWEDBY ACCOUNTING OFFICE Date 1 �' <br /> Masterfile Record Pink <br />