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AdMIL SAN JOAQUIN COUNTYTIVIRONMENTAL HEALTH DEPARTWNT RIME® MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility ❑New EH Pr ram and New Facil SEP 2 2 2011 Facil' ID Ft O Pro ram Record ID B � Facility Address laC' c Cel Gk --4a ( `mY��' C p, q 3?tp ENVIRONMEN-AL HEALTH (Please check the appropriate description and specify,size,number of units and pertinent information.) PERMIT/SERVICES FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course uire : 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 ❑ Ice Plant ❑Special Event Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser-Number of Containers in Multi-Head Unit COPA ❑State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator-----------Tons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) ----------❑Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility--------------–---❑Conditionally Authorized(CA) ❑Conditionally Exempt(CE) ❑ 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 UST A and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel—Number of Units ❑ Jail or Exempt Institution---Number of Units Employee Housing(2700)Use Employee Hous/no/Labor Camp Appl/cat/on Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ uic Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑Out of Service PooUSpa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm----Maximum number of birds ❑ Kennel TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) 13Tattooing(4121) E3Body Piercing(4120) y Permanent Cosmetics(4122) �� LIQUID WASTE PROGRAM(4200) 111111 lll��` ❑ Pumper VehicleRegistration# 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/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles w of units) ❑ Dumpsters>20 cu yd(s of units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4600) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑Small Generator ❑ Limited Hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility ❑2-10 (311 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PINS EHD 4042-003 Blue Appllcat/on Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMIT VALID to ❑ Food Handier ❑Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date Al _t5 48-02-034 MASTERFIIF RECORD INFORMATION PINK 11115/07