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SAN JOAQUIN COUNTY ili;' ZONIYILNIAL flEAL11-1 U1:1'AR N'1 �tr ' iVIASTERFILE ,.- ORD INFORMATION FORM ew EH Pro ram at Existing FacilitX ❑New EH Pro ram and New Facilit Facility ID (- oon R`71Z Program Record ID Pi2V Sa-3 ?I Facility Address (. jc' (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 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 Dalry ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Flcad Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ 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(arms 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(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle--Registration# License# Capacity Vehicle# ❑ Pumper Yard 11Package 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 ENVIRONMENTAL HEALTH ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage 112- 1Facility----- 2- 1� DEPARTMENT NO LONGER PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form INSPECTS WASTE TIRE EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR FACILITIES. It is a State run CONTACT PERSON Day Ph program effective 7/1/2017. PROGRAM'ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# 4&3& PERMIT VALID to 11 Food Handler ❑ Check# AMOUNT PAID Date INVOICE# Cl Cash REVIEWED BY ACCOUNTING OFFICE Date 2yz) c7�- 48-02-034 Masterfile Record Pink 11118/03