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SAN JOAQUIN COUNTY ENV N NTAL HEALTH DEPART1Vl�T <br /> MASTERFILE RECORD INFORMATION FORM <br /> New E11 Program at Existing Facility ❑New EH Program and New Facility <br /> Facilit ID FR _0 Of`i`I2S Program Record ID PR6512 3 7 711 <br /> Facility Address 3 61 S /fid A r t 9d _'AoC�_ ) n <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines--Number of Units <br /> ❑ Retail 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 <br /> to El Ice Plant <br /> ❑ Special Event --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ <br /> El Grade A Dairy 13 Grade B Dairy Milk Dispenser--Number of Containers in Multi-Ilcad Unit <br /> CUPA ❑ Stale Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM (2200) <br /> ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/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 /> ❑ Permit-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 USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ <br /> El Ilotel/Motel-------Number of Units Jail or Exempt Institution-------Number of Units <br /> Employee Housing(2700) Use Employee HousinzlLahor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 13 Environmental Assessment 13UST-CAPSite 13 Local HW Cleanup Site 13NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water 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 /> El Kennel <br /> ❑ Poultry Farm -------Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> [3 Tattooing(4121) ❑ Body Piercing(4120) 13 Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> [3 Pumper Vehicle-Registration# <br /> License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill E3 Transfer Station 13 Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> `�,'!Waste Tire Facility [3 Compost Facility ❑ Process/Ree cle Facility 11 CIA Landfill Site <br /> Y y <br /> 171 Refuse Vehicles--Number of Units p <br /> ❑ Dum sters>20 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> [3 Primary Care C3 Acute Care ❑ Skilled Nursing ❑ Large Generator El Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station 13 Veterinary Clinic ❑ Common Storage Facility----❑ 2- 10----- [3 11 -60 -13 >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> rINSPECI,011 <br /> RAM ELEMENT ` -7 q� ) FEE ❑ Surcharge FEE ❑ Other FEE <br /> # PERMITVALID to ❑ Food Handler <br /> ck# AMOUNT PAID Date INVOICE# <br /> h REVIEWED BY J� 3/23 E� ACCOUNTING OFFICE (f✓ Date 3 aG/ DS <br /> Masterfile Record Pink <br /> 48-02-034 <br />