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7 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RF YM� <br /> MASTERFILE RECORD INFORMATION <br /> ,,FORM I' CE�vNT <br /> ❑ New EH Pr ram at Existing Facilit L7New EH Program and New Facility, Mqy 19 `Q <br /> Facility ID Program Record ID ✓c, <br /> FacilityAddress./2 � ar�c��r�� ad /c. �� >!�LL /} qCr SRO��NC <br /> (Please check the appropriate description and specify size, number of units and pertinent information.) T/jf <br /> FOOD PROGRAM(1600) 47- <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 ❑ with Meat Market only ❑ Multiple Departments❑ Prepackaged 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(2218) --------❑ 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 /> ❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution ----Number of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Camg Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW 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 I ea M—Pool 1:31Spa ❑ 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 /> ❑ 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(#of units) ❑ Dumpsters> 20 cu yd(+f of Units) ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility 112- 10 ❑ 11 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICA N FOR THI FACILITY AND/OR PROGRAM <br /> CONTACT PERSON UIC-��Irk, r74 d C 5 Day Ph q2-5 452•'r,l30 Night Ph q25• -mg-gR(m <br /> PROGRAM ELEMENT FE 13 Su <br /> FE 11 Other FEE <br /> INSPECTOR# PERMIT VALID S ZO t0 1 3 ❑ Food Handler <br /> ❑ Check# isiL AMOUNT PAID INVOICE# �370zS <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date Sj <br /> 48-02-034 C l MASTERFILE RECORD INFORMATION PINK 11/15/07 <br />