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r 1 <br /> SAN JOAQUTIN COUNTY ENVIRONMENTAL HEALTR DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility New EH Program and New facility <br /> Facilif ID DOU D!J Pro ram Record 111D 53 <br /> Facility Address S�1 1ilskre �Iye 7r�'of,K iL,),. 9szo3 <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yes❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only El with Food Preparation ❑Fending 14tachines—Number of Units <br /> El Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vchicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> 11Temporary Food Facility—Dates of operation from to El 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-Ilead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IiA7.ARDOUS WASTE PROGRAM(2200) i <br /> ❑Hazardous Waste Generator.-- Tons Generated Per Year ❑ Recycle I Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2219) ❑ 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`Paste <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 /> ❑ Ilotc1/1ltotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee ITousittjz abor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION C014TROL(3000) <br /> ElEnvironmental Assessment ElUST-CAPSite ElLocal MV Cleanup Sife, El NPL(SEP Cleanup Site El UIC site* <br /> El Abandoned IIW Site Elnon-NPUSEP Cleanup Site ❑RWQCB Cleanup Site ❑`Yater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Ppol ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> El Poultry Farm Maximum number of birds 11 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4204) <br /> El Pumper Vehicle—Registration# License# Capacity Vehicle ft <br /> ElPumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> L1 Landfill E] Transfer Station 11 Ag/Cannery Waste Site 11 Sludge/Ash Site <br /> Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA-Laadfill Site <br /> ❑ Refuse Vehicles—Number of Units 11Dumpsters>20 cu yd —Number of Units ElFarm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care El Acute Care ❑ Skilled Nursing 11 Large Generator El Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility---E] 2- 10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIIVSFTTD 46-02-403 BlueApplica6on Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON _ Day Ph Night Ph <br /> PROG1L4ni ELENIE.N,T'`_L'1`1 L{ _ FEE J4'/ 11Surcharge FEE F1 Other FEE — <br /> INseFCTOR#a� ISS ERMITVALtD --- to El Food Handler-- <br /> ❑ cr«�� r _ AJhTOUNT P 3.ID -- — Date III-VOICE(( --- --- <br /> ❑ Cash l�Evir,WE>BY 8� a ��, AC couIaa,,! <br />