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SAN JOAQUTIN COUNTY ENVIRONMENTAL HE ALM DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility 04ew EH Program and New Facility <br /> Facilif ID /9� Program Record ID `J <br /> Facility Address22 a JnQ, V-e ho, F Sl(A0,)"(.A q S 320 <br /> (Please Check the appropriate description and specify sizenumber of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YEs El No El <br /> ❑ Commissary ❑ Dry storage only 11 with Food Preparation ❑Fending Machines—Number ofUnits <br /> 1:1 Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ElMobile 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) t <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-lay-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 Pi forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/1`fotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee 7foasinglLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 11 Environmental Assessment ❑UST-CAP Site 11 Local 11W Cleanup Site, L1NPL/SEP Cleanup Site 11 UIC Site <br /> ❑ Abandoned IlW 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. ❑Ppol ❑ 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(4121) ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> El 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 /> �Yaste Tire Facility 11Compost Facility 11Process/Recycle Facility 11CIA-LandfillSite <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 El Acute Care ❑ Skilled Nursing 11 Large Generator 11 Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--11 2-10 ❑ ll-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIf'SEFID 46-02-003 BlueApplicalion Form <br /> EMERGENCY NOTIFICATION FOP THIS FACILITY ANO/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGP-01ELENIENT_ Liq q FEE El SurchargeFEE '- F1Other FEE _ <br /> INSPECTOR# aL->_ PEFMITVALID to ❑ Food Handler_ <br /> E1 Checkf --AIMOUNTPAID - — Date 11IV010E#y -- / _--- <br /> ❑ C azh P�r:ViE�'m BY 2 AICOUC4TINCi OFFICE Date I r �( <br /> — —t� _ �j--�— __ _- - = -- -- —_ <br />