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SAN JOAQUIN COUNTY E RONNF,,NTAL HEALTH DEPAR'_ ENT <br /> MASTERFILE RECORD I`-FORNIATIOr'FORM <br /> New EH Pro am and New Facility <br /> ❑New EH Proeram at Existing Facility ' <br /> Program Record ID Fka <br /> Facility ID <br /> Facility Address ANS S. GU\\-p <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> S Footage Food Handlers Course required: Yes ❑ No El <br /> uare <br /> ❑Restaurant: Seating Capacity q ❑Vending Machines--Number of Units <br /> ❑ Commissary ❑ Dry storage only ❑ with Food <br /> Preparation <br /> h Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Cl Retail Market----Square footage Color <br /> C3 Mobile Food Vehicle-----Make Vehicle TypeLicenser Sticker# <br /> Registration# Color <br /> El Mobile Food Prep Unit--Make Vehicle TypeLicense# Sticker# <br /> to <br /> Registration# 11Ice Plant <br /> ❑ Temporary Food Facility-----Dates of operation from to ElProduce Stand <br /> ❑ Special Event --Dates of operation from <br /> DAIRY PROGRAM(2000) <br /> ElGrade B Dairy C3 Milk Dispenser---Number of Containers in Multi-Head Unit <br /> El Grade A Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZAPOUS WASTE PROGRAM( ) L�J \a-�S ❑ Recycle/Exempt System(2299) <br /> ER"Hazardous Waste Generator------------Tons Generated Per Year Y 27-17) <br /> ❑ Silver Only ❑ Appliance Recyclers <br /> ❑ CRT Offsite Handlers (_218) y ����(2222) <br /> Tiered Permitting Facility—-------2-----— ElConditionally Authorized(CA) ElConditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fired Unit ❑ PetTnit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(23 90) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> 11Jail or Exempt Institution----Number of Units <br /> El Hotel/Motel-------Number of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment C1UST-CAPSite ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RN1'QCB Cleanup Site ❑ Nater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) [I out of Service Pool/Spa [I Natural Bathing Area <br /> Number of Pools/Spas at Facility Cl Pool <br /> ❑ Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm-------Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle# <br /> [I Pumper Vehicle--Registration# License# p y <br /> F-1 Pumper Yard <br /> [I Package Treatment Plant ❑ Chemical Toilets- - --Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> ❑ Transfer Station ❑ Ag/Cannery Waste Site <br /> ❑ Landfill ❑ CW Landfill Site <br /> ❑ Process/Recycle Facility <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Farm/Ranch Cleanup Site <br /> 11 Refuse Vehicles--Number of Units 1:1 Dumpsters>20 cu y d----Number of Units <br /> MEDICAL WASTE PROGRAM(4500) ❑ Small Generator El Limited Hauler <br /> El Primary Care (3 Acute Care ❑ Skilled Nursing ❑ Large Generator <br /> [I Common Storage Facility-----02- 10------ ❑ 11 -60-----El >60 generators <br /> 11Transfer Station ❑ Veterinary Clinic <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PiVS EHD 46 07-003 Blue Application Forn: <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROG�RA Mh <br /> CONTACT PERSON Day Ph <br /> FEE C3Surchar e F E LJ Other FEE <br /> PROGRAM ELEbIENT 'aQ� 0S F-1FoodHandler <br /> INSPECTOR# SSq PERMIT VALID \ O5 to ` �\ <br /> Date INVOICE# K <br /> 1:1Check# ATNIOUNT PAID Date <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE <br /> asterfile Record Pink <br /> 48-02-034 <br /> 10/6/2003 <br />