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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ew EH Pro am at Existing Faeili ❑New EH Proin and New Facility Facility ED "50 Pro ram Record ID Facility Address I l' � 5 Gtilb Avc. c)r' S2`E6 (please Check the appropriate description and specify size number of units and Pertinent information) FOOD PROGRAM(1600) ❑Restaurant: Scaring 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 ❑MobRe Food Vehicle—Make Vehicle Type Color - Registration N 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 CUPA ❑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) iE3 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 ASI' 1 Qtwk in UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms } 4wlc V`3r� �64� HOUSING PROGRAM(2400) - �- �.t •� ,� Ma 6Z .41 ❑HoteUMotel—Numlxr of Units ❑Jail or Exempt InstituAn—Numtnr of Units Employee Iiousing(2700)Use&wlovee Hoasine/Labor Camp APPUcadon Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑Environmental Assessment ❑UST-CAP Site ❑Local IIW Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site ❑Abandoned HW Site ❑non-NPIJSEP Cleanup Site ❑RWQCB CleAr up Site ❑Water Quality Remediation Site RECREATIONAL 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 ❑Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑Tattootag(412t) ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) 13 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/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator O Small Generator ❑Limited Hauler ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--O 2-10—❑ 11-60—❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PHSGRD 46-01-003 Blue Applimflon Form EM GENCY NOTIFICATION FOR TRIS FACILITY ANDIOR PROGRAM CONTACT PEI2SON &6GalJNAN Day Ph ?O'i ;iq-`910 Night Ph PROGRAM ELEMENT `1,?1t1Q FEE ❑Surcharge FEE ❑ Other FEE INSPECTOR# 1�1� PERMIT VAUD . to ❑Food Handler ❑ Check# AMOUNT PAID Date INVOICE# El cash REVIcwEDBV -`A ACCMNnNGOFFIce Date `�