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SAN JOAQUIN COUNTY ENVIONMENTAL HEALTH DEPARTMIOT MASTERFILE RECORD INFORMATION FORM ew EH Program at Existing Facil [:]New EH Program and New Facility ne Facility ID FA ��+�� Program Record ID�c7S�� l �CIS Facility Address 79 311 C . I Ieyen4S.+, A (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 ❑ 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 Registration # License # ❑ Mobile Food Prep Unit -Make Vehicle Type Registration # License # ❑ Temporary Food Facility ----- Dates of operation from to ❑ Special Event --Dates of operation from to _ Color Sticker # Color Sticker # ❑ Ice Plant ❑ 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 LISTA and B forms HOUSING PROGRAM (2400) ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution -------Number of Units Employee Ilousing (2700) Use Employee Housine/Lahor Can►p 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) ❑Out of Service Number of Pools/Spas at Facility 11 Pool ❑ Spa Pool/Spa El Natural Bathing Area VECTOR CONTROL PROGRAM (4000) 1:1 Poultry Farm -------Maximum number of birds ❑Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) El Tattooing (412 1) C1 Body Piercing (4120) El Permanent Cosmetics (4122) LIQUID WASTE PROGRAM (4200) El Pumper Vehicle -Registration # License # Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units SOLID WASTE PROGRAM (4400) 11 Landfill El Transfer Station 11 Ag / Cannery Waste Site ❑Sludge/Ash Site Waste'rire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles --Number of Units ❑ Dumpsta's > 20 cu yd ----Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (400) El Primary Care E] Acute Care ❑ Skilled Nursing 11 Large Generator ❑Small Generator ❑Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ---- El 2 - 10------- ❑ 11 - 60 ------ ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 BlueAppliention Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON � Day Ph Night Ph PROGRAM ELEMENT 9 71_a b FEE ❑ Surcharge FEE ❑ Other FEE INsrEc'rol; # 00W) PERMIT VALID to ❑ Food Handler ❑ Check # AMOUNT PAID Date INVOICE # ❑ Cash REVIEWED BY TK i 0 2 Q S ACCOUNTING OFFICE Date ( —7 Masterfile Record Pink 48-02-034 10/6/2003