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SAN IOAQUIN COUNT'ENVIRONMENTAL HEALTH DEPAR'A'AIE T MASTERFILE RECORD INFORl1'IATION FORM w ❑New EH Program at Existing Facility New EH Program and New Facility= "� �!g 60/ Facilif h) ( t2 Program Record ID Facilit Address \ i m\ `0 1� u cA qS��3 v �. on �" Qtr► 1'� Ul c t��lA S� t� t►��r11� � � Vc, dl V (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) f0er all ❑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 Muiti-head Unit COPA ❑ State Facility Surcharge(2399) HAZARDOUS 1VASTE PROGRAM(2200) 9 ❑ Harardous Waste Generator--- 'Ions Generated Per Year ❑ Recycle f Egen'pt System(2299) ❑ CRT OlTsite handlers(2219) ❑ Silver Only(2222) _ ❑ .Appliance Rccyclers(2217) Tiered rermitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit-By-Rule Fixed Unit ❑ Pemut-By-Rule Household hazardous SVastc ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE`PANIC(UST)PROGRAM(2300)Use USIA and B formes HOUSING PROGRAM(2400) ❑ Hotelllllotel Number of Units ❑Jail or Exempt Institution----Number of Units_ 1E.mployee Housiag(2700)Use E'urplayee gousin�l bor Camp Appfica(iorr.Form SITE MITIGATROPl(2900) UNDERGROUND INJECS-ION!CONTROL(3000) ❑ 1En`dronmeatal Assessment ❑UST-CAP Site ❑ Local 111V Cleanup Site. ❑ NPLfSEP Cleanup Site ElUIC Site 11Abandoned 1I1'Y Site 11non-NP.USEP Cleanup Site ❑RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility. ❑ Pool ❑ Spa ❑ Out of Scr�ice Pool/Spa ❑ Natural Bathing Area VECTORCO14TROL PROGRAM(4000) ❑ Poultry Farm Maximuan number of birds ® Kennel TATTOO,BODY PIERCING,PERMAIIENT COSMETIC PROGRAM(41W) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) Pumper Vehicle—Registration ft License rY Capacity Vehicle ff ❑ Pumper Yard ❑ package Treatment Plant ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ 'Transfer Station ❑Ag/Cannery AV2ste Site ❑ Sludge/Ash Site 1 R'Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ 12efuse VeLicles--Number of Units ❑ Dumpsters>20 cu yd —Number of Units ❑ Farm/R.-ancla Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ I'rimary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----❑ 2- 10 ❑ 11 -60----❑ >60 gcncr:tors PUBLIC WATER SYSTEM PROGRAM(4600) (fsc:PH'SFHD 46-02-003 There ApElica(ion f-urrrt EMERGENCY NOTIFICATION FOR Tills FAC9LITY Arao/orz PROGRAPA CONTACT PERSON Dav Ph Night Ph PROGR.A51FLEiltE`T `CND IEEE / ❑ Surcharge FLE,E El Other FE -- -- Ir;srrcrar 2 L PI i Rt17 VALiD to_ -- CI Food handler—---_— Cl C'1,_ck� r�.nztlt;,I e I'��➢[� liate It rvutt !f 0 Co:h ts