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SAN JOAQUIN COUNTY EIRkONMENTAL HEALTH DEP NT ��^C��v�D 'n MASTERFII E RN c ORD INFORMATION FORM New EH Pro am at ExistingFacility ❑New EH Program and New Facility 7 2 0 0 6 FacilityID 37 Lf Ll Program Record ID _ 'e 0 5 2 b 3 g 3 AUG Facility Address 323 3 E. L Do►n is Rb 1 sfif6 IG/-^J ENVIRONMENT HEALTH (Please Check the appropriate description and specify si [s and pertinent information.) PERMITISERVICES FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity . - Squareawasm.. - Food Handlers Course required:—YES O-ND❑ - ❑ Commissary ❑ Drystorage 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 ❑ 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 CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) , AHazardous Waste Generator-----------Tons Generated Per Year 5-I_ t/�L TB 'I i ❑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 forms HOUSING PROGRAM(2400) - -❑ Hotel/Motel-------Number of Units ❑ Jail-or Exempt Institution—Number ofUnits 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 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----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------011-60-----❑ >60 generators - PUBLIC WATER SYSTEM PROGRAM(4600) Use PJVS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIs FACILITY ANDIOR PROGRAM _CONTACTPERSON f ¢r CLA e2 Day Ph Bibb- 2'10 ) Night Ph PROGRAM ELEMENT 2 22 D FEE Z06 ,06 `�❑ Surcharge FEE ❑ Other FEE INSPECTOR# 3 PERMIT VALID _ I Ut. to /L 31 I �- ❑Food Handler ❑ Check# - AMOUNT PAID Date ` INVOICE# 5 l\-_7 I ❑Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 - Masterfile Record Pink - 10/6/2003 -