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SAN�JOAQUIN COUN _. .O TY EN NMENTAL HEALTH DEPAR 1 i MASTERFIL E RECORD INFORMATION FORM ❑New EH Program at Existing Facility New EH lP�ro�ram and New Facilit Facility ID y 6 D 1-7-7 O O aE Program Record ID �Sa �S� 771 Facility Address ' 3� W I ISOin VV��/ (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) El Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes ❑ No ❑ ❑ Commissary ❑ Dr}-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# El Temporary Food Facility-----Dates of operation from to 13 Ice Plant 13 Special Event --Dates of operation from to 13 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) ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System (2299) ❑ CRT Offsite Handlers (2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility------------------El 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 USTA and B forms HOUSING PROGRAM(2400) El Hotel/Motel- Number of Units ❑ Jail or Exempt Institution-------Number of Units Employee(lousing(2700) Use Employee HousinglLahor 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 IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Numbrr of Puols'Spas at Facility El Pool 13 spa C3 Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm -------Maximum number ol'birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4 122) LIQUID WASTE PROGRAM(4200) License# Capacity Vehicle# ❑ Pumper Vehicle -Registration# V ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Process/Ree cle Facility El CIA Landfill Site !�\Paste"('ire Facility ❑ Compost Facility y� ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ENVIRONMENTAL HEALTH ❑ Primary Care El Acute Care ❑ Skilled Nursing El Large Generator LONGER ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ---❑ 2-rDEPARTMENTNO INSPECTS WASTE TIRE PUBLIC WATER SYSTEM PROGRAM(4600) Use P1VS EHD 46-01-003 Blue Application Forn FACILITIES. It is a State run EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR', program effective 7/1/2017. CONTACT PERSON t�&iMe- Al V61 re-Z- Day Ph H 9 8� 1,. PROGRAM EtxNIENT 14. 1 Lf Q FEE ❑ Surcharge FEE ❑ Other FEE �� , El Food Handler INSPECTOR# 00L00 PERMIT VALID to ❑ Check k AMOUNT PAID Date INVOICE# 13 Cash REVIEWED13N' �� Lj )as ()� ACCOUNTING OFFICE Date d� Masterfile Record Pink 48-02-0:4 10/6!200: