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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEI'ARl'N'il NT <br /> MASTERFILE ORD INFORMATION FORM <br /> ❑New EH Pro ram at Existing Facilit New EH Pro ram and New Facility <br /> FacilitX ID 6c 00 IS-33 Program Record ID <br /> Facility Address t A lr/s,,,., C11-Sx, CA 9'5 20 S <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES❑ No ❑ <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 /> Rcgislration 11 License# Sticker# <br /> ❑ Mobile Food Prep Unit--Make Vchicic Type Color <br /> Rcgislration 11 _ License 11 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 Dalry ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ 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 ❑ .tail or Exempt Institution------Number of Units <br /> Fniploycc(lousing(2700)Use Employee 11ousint/Lahor Cama Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAI'Site ❑ Local IIW Cleanup Site ❑ NPL/SEI'Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEI'Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site' <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PooWSpas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm-------Maximum number of birds ❑ Kennel <br /> TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle--Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard 11Package 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 _❑_'arm/Ranch_Cleanun_Site <br /> MEDICAL WASTE PROGRAM(4500) ENVIRONMENTAL HEALTH <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator DEPARTMENT NO LONGER <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----❑ 2 INSPECTS WASTE TIRE <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS END 46-02-003 Blue Application Fo� FACILITIES. It is a State run <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/ol program effective 7/1/2017. <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT L"_7 L D FEE 2p ❑ Surcharge FEE 11Other FEE <br /> INSPECTOR# �-f �3� PERMIT VALID D 'to 00(05--- ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date— INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date Z( 0 <br /> 48-02-034 Masterfile Record Pink <br /> 11/18/03 <br />