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SAN JOAQUIN COUNTY M.AONMENTAL HEALTH DEPARI'w&NT �� MASTERFILE RECORD INFORMATION FORM ONeW EH Program at Existin Facility 0NewEHProgramandNew Facili _ Facility ED Pro ram Record ID _ Facility Address S -7 -7 Fr"C41 C4-114p (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 ❑ 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 Registration# Color License# Sticker# ❑ Mobile Food Prep UDit—Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to 11 Ice Plant ❑ Special Event --Dates of operation from to 11 Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit CUP A ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) _ azardous Waste Generator-------- S 0 Recycle/Exempt System(2299) --Tons Generated Per Year S� Z ❑ 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 lastitution—Number of Units Employee Housing(2700) Use Employee Housine/Labor Como 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(412 1) - ❑ 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 ❑Siudge/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-----❑ 2-10----❑ 11-60---❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PNS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACTPERSON 6t'lJid AI- yVgk/— Day Ph Night Ph PROGRAM ELEMENT '221-1 FEE 1 I ,OV ❑Surcharge FEE ❑Other FEE INSPECTOR# 23 1 -1 PERMIT VALID j 1 d "7 to 1 2 3 I ,9 ❑Food Handler ❑ Check# - AMOUNT PAID Date INVOICE# _ 13 cash REVIEWED BY ACCOt1NTINGOFFICE Date ( ©(, 48-02-034 C�� Z 2 Z() 2 722 - Mast tic Record Pink - 10/6/2003