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IA""ENT 1J <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED <br /> MASTERFILE RECORD INFORMATION FORM APR 15 2010 <br /> ❑New EH Program at Existing Facility ❑New EH Program and New Facility SAN JOAQUIN COUNTY <br /> Program Record ID J3ENVIRONMENTAL <br /> Facility ID EATH <br /> DEPARTMENT <br /> Facility Address 3 2.2 E- F , -S7`°`=C7V") Y24 2— <br /> (Please <br /> (Please heck the appropriate description and specify size,number of units and�Iertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑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 '— 2-00 O ❑with Meat Market only ❑ Multiple Departments Wrepackaged 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 to ❑ Ice Plant <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) ' <br /> ❑Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser---Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator— Tons Generated Per Year ❑Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(22 is) ❑ 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 UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑Ilotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use F,rnplow lfousinp/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned 11W Site ❑non-NPLISEP 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 /> ❑ Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited IIauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility---[] 2-10 ❑ 11-60-----❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use Pff'SFHD46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON t �4 4� o Day Ph SO 0 Niglit Ph <br /> PROGRAM ELE/MEN,T? FEE 3 ' �� ❑ Surcharge FEE Other FEE <br /> INSPECTOR# t(]Z PERMIT VALID to 3 ❑ Food handler <br /> �l Check# MIOUNT PAID Date 1 S I 1 0 RTZ,-- INVOICE# ?i0) t40 <br /> ❑ Cash REVIEWED BY 6 v )2�.2I ACCOUNTING OFFICE DdtC g <br />