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SAN JOAQUTfN COUNTY ENVIRONMENTAL HEALTH DEPARTAIENT <br /> MASTERFILE RECORD INFORI 4ATION FORM <br /> ❑New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facilif ID Q D D S`5-S-S-Pro ram Record ID hD S3 <br /> Facility Address 2&G z tV <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YES❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only El with Food Preparation ❑Fending Machines-Number of Units <br /> ElRetail Market—Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit-Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event -Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(200 ) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Muth-Ilead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) t <br /> ❑Hazardous Waste Generator'.=—Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pen-nit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> .UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and S forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotenlotel Number of Units .❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee Housi"K4bor Camp Applicadan Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local IINV Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned HBV Site ❑ non-NPLrSEP Cleanup Site ❑RWQCB Cleanup Site ❑BVater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds 11 Kennel <br /> `TATTOO 13ODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle-Registration# License# Capacity Vehicle€€ <br /> ❑ Pumper Yard ❑Package Treatment Plant- ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag I Cannery Waste Site ❑ Sludge/Ash Site <br /> Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA-Landfill Site <br /> ❑ Refuse Vehicles-Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) ENVIRONMENTAL HEALTH <br /> 11 Primary Care 11 Acute Care IJSkilled Nursing 11 Large Generator { <br /> ❑ Common Storage Facilit <br /> ❑ Transfer Station ❑Veterinary Clinic g Facility-0 DEPARTMENT NO LONGER <br /> - <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UscP[VSEHD f6-02-003 BhteApplicalion i INSPECTS WASTE TIRE <br /> FACILITIES. It is a State run <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANf <br /> CONTACT PERSON- __ Day Ph program effective 7/1/2017. <br /> PROGit01ELEf1ZETrT t{ q_O FEE ❑ Surcharge FEE - ❑ Other FEE <br /> INSPECTOR# � PbRMITVALID to ❑ Food Handler_ <br /> ❑ check ff A1140UNT PAID Date INVOICE It <br /> l_J Cash REVIEWED BY ACCOUNTING OFFICE Date <br />