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SAN JOAQUIN COUNTY INVIRONMENT AL HEALTH DEPARIWENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Progrra-gym, at Existing Facility ❑New EH Program and New Facility Facility ID Program Record ID 7 kl?) Facility Address Irk► A), yr Ynci, G —r (Please check the appropriate description and specify siz6lAumber of nits and pertinent information.) 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 ❑ 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 Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ NlpIFgivtc�Area VECTOR CONTROL PROGRAM(4000) R E C 17-1 Poultry Poultry Farm-------Maximum number of birds Kenne TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) JUN 2.8 701.3 ody Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art FacilitI67&g" El Body Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) Body Art-Temp Evo I 1��(T�`131) LIQUID WASTE PROGRAM(4200) HEALTH DEPARTMENT ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ElPumper Yard I-] Package Treatment Plant ElChemical 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(#of Units) ❑ Dumpsters>20 cu yd(#of Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112-10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITYAND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM EL MENT CiltoFEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMIT VALID -7-I't3 to 3 Cr 1 ❑ Food Handler ❑ Ch ck# AMOUNT PAID /�0 O Date I INVOICE# °2` 1; o Cash REVIEWED BY / ACCOUNTING OFFICE -&�—Date ZLZ3 48-02-034 MASTERFILE RECORD INFORMATION PINK 8102/12