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SAN JOAQUIN COUNTY WVIRONMENTAL HEALTH DIVIS19N MASTERFILE RECORD INFORMATION FORM(EH 00 69) ❑ New EH Program at Existing Facility ®New EH Pro rata and New Facilil �Facilitj ID Program Record ID Facility Address 23265 es. STS cut.. a°l u.) . 4tiw,.s�psa Irk. (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating CapacitySquare Footage Food Handlers Course required: Yes❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation Elven,ding 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 llDairy 11 Grade B Dairy El Milk Dispenser---Number of Containers in Multi-Head Unit CUPA ❑:State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) — - �Iazardous Waste Generator-------<-5--------Tons Generated Per Year Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt rm (CE) r� ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste �EIIABOVEGROUND STORAGE TANK FACILITY(AST)(2390)----Numbcr of AST A 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 HousinalLmbor Canin 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 ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farni-- -Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4106) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ 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 ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----132- 10-------❑ 1 l -60------❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EM0069 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON ClDtSbWK Q y S1%U— Day PhV.O\�-S68g1.1'L Night P 'S -%309 PROGRAM ELEMENT FEE ` ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMIT VALID t0 ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICL It rl Caslt RLviL'wim DY ACCOUNTING Gy19CL Date j BilO ,.