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SAN JOAQUIN COUNTY E,.�IRONMENTAL HEALTH DEPAI-ssi.IIENT MASTERFILE RECORD INFORMATION FORM ❑New EH Program at Existing Facility ❑New EH Program and New Facility Facili ID Oil Program Record ID R Facility Address 1145 W yosem lTE kV6 (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 ❑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 COPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) 811azardous Waste Generator----------Tons Generated Per Year 1 S Tv AI ❑Recycle/Exempt System(2299) 11CRT Offsite Handlers(221 g) 13Silver 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 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 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# 13Pumper Yard ❑ Package Treatment Plant IJChemical 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------❑ 11 -60------El >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWSEHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON �t Day Ph Night Ph PROGRAM ELEMENT d FEE ❑ Surchha/ FEE yy---- El Other FEE IrvseecroR# 7,(0`T O PERMIT VALID / O to / /p ❑ Food Handler ❑ Check# AMOUNT PAID Date_ `� INVOICE# 1:1 Cash REVIEWEDBY - rI ACCOUNTING OFFICE Date i 48-02-034 1.0/6/22003003 Masterfile Record Pink