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�.. *AW SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT . MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility WW EH Program and New Facility Facility ID L90 S 2— Pro ram Record ID Facility Address 201 VJ• 19A I K& \ (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs❑ No❑ ❑ Commissary ❑ Drystoregeonly ❑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 ❑Glade 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 S �'+"! ❑ 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 farms HOUSING PROGRAM(2400) ❑ HotelMotel----Number of Units ❑ Jail or Exempt Institution—Number of Units Employee Housing(2700)Use Enwlovee HousinyEabor 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 ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm—Maximum number of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑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---NumberofUnits ❑ Farm/Raoch 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 FACILITY AND/OR PROGRAM CONTACT PERSON 41 Day Ph 2 15 Night Ph PROGRAM ELEMENT 27 2 0._ FEE aO•QO XSurcharge FEE ❑Other FEE INSPECTOR# Q31-7 PERMITVALID //daci to /L4?/4v� ❑ Food Handler ❑Check# AMOUNT PAID Date INVOICE# ❑cash REVIEWED BY ACCOUNTING OFFICE Date 48-02.034 Masterfile Record Pink 10/62003