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SAN JOAQUIN COUNTY E4 ONMENTAL HEALTH DEPARONT MASTERFILE RECORD INFORMATION FORM ❑New EH Program at Existing Facility ew EH Program and New Facility Facility ID I'A 0 0 Lo q 1 Pro ram Record ID 1� 3 Facility Address t IAC/ 0 K v� Kv t c (Please Check the appropriate description and speci y 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 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 ❑ 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 PooWSpas 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-----❑ 11-60-----❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON bAVjZ> Day Ph -13 —0 6;X Night Ph PROGRAM ELEMENT ® FEE D ❑ Surcharge FEE ❑ Other FEE INSPECTOR# ziiot\ PERMIT VALID `Z(1 �dT to TOS ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE —Zo� DateZ3 d 48-02-034 Mastetfile Reeord F pk I AlKnnn)