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SAN JOAQUIN COUNTY ErVRONMENTAL HEALTH DEPAR :NT MASTERFILE RECORD INFORMATION FORM New FH Prno. — ee rte.. - Inc nn rlugram ana Ileal a�rr.. v Program Record ID (/ a1,ja4(y f Facility Address Syb N, (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 11 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 Color Registration # License # Sticker # ❑ Mobile Food Prep Unit --Make Vehicle Type Color Registration # License # Sticker # ❑ Temporary Food Facility -----Dates of operation from to El 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 CU PA ❑ State Facility Surcharge (2399) HAZZA�DOUS WASTE PROGRAM (2200) 13 Hazardous Waste Generator ------------Tons Generated Per Year 45;;�1 ❑ 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 ❑ Perrnit-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 Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor 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 Remofation 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# 1:1Pumper Yard 11Package Treatment Plant ElChemical 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 Cl Veterinary Clinic ❑ Common Storage Facility ----- 112-10 ------- 011-60 ------❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 BlueA plication Form CONTACT PERSON EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM Day Ph Night I PROGRAMELE,VEjNT 2zZ0 FEE 200 INSPECTOR # O J� PERMIT VALID // or ❑ Check # / / AMOUNT PAID ❑ Cash REVIEWED BY 48-02-034 10/6/2003 ❑ Surcharge FEE ❑ Other FEE to ❑ Food Handler Date ACCOUNTING OFFICE INVOICE # Date (01 Record Pink