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SAN JOAQUIN COUNTY E ON'.NIENTAL HEALTH DEPAR ANT GJ' IAl MASTERFILE RECORD INFORMATION FOP ❑New EH Program at Existing Facility New EH Program and New Facility Facility ID QO \ 5 Program Record ID OS Z q3 Facility Address I I I l7 vel. Ke'_h_1e MQy? L11 - S"'i to 20—e> (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 13 Retail Market----Square footage 11 with Meat Market only' [I Multiple Departments 13 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------------------El 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 CST A and B fornrs HOUSING PROGRAM(2400) ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units Employee housing(2700) Use Employee Hous n z Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) El Environmental Assessment ElUST-CAPSite El Local HW Cleanup Site ElNPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RNN'QCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility 11 Pool El Spa El Out of Service Pool/Spa El Natural Bathing Area VECTOR CONTROL PROGRAM(4000) El Kennel ElPoultry Farm -------Maximum number of birds TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) 13 Tattooing(412 1) ❑ Body Piercing(4120) El Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) F-1PumperVehicle -Registration# License# Capacity Vehicle# El Pumper Yard ElPackage Treatment Plant ❑ Chemical Toilets ------Number of Units SOLID WASTE PROGRAM(4400) El Landfill El Transfer Station El Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Process/Recycle Facility El CIA Landfill Site �Wastc'1'ire.Facility ❑ Compost hacilih y ❑ Iteruse Vehicles--Number ol'Units ___ ❑ I)umpsters>20 cu yd----Number of Units_ ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) El Primary Care El Acute Care El Skilled Nursing ❑ Large Generator ❑ Small Generator El Limited Hauler El Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----El 2- 10- El I1 60--- - El >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) L-se PIVS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT 1 I I V FEE ❑ Surcharge FEE ❑ Other FEE f D to `13DlD ❑ Food Handler INsr►ccrot;# ddG?D S� Plainafrvnl_Io 11�iloS (,v ❑ Check 9 AMOUNT PAID G� Date INVOICE# 11 Cash REVIEWED BY ��, I 0 "� OS ACCOUNTING OFFICE Date ` 5 Masterfile Record Pink 48-02-034 10/6/2003