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` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD L tFOP-1LATION FO &I(EH 00 69) <br /> ❑ New EH Pro am at Existing Facility ew EH Prograrri <br /> and New Facility <br /> Facili ID rA C v 4 � Program Record ID (Z O Sa 1 3-7 <br /> Facility Address 23 C-- aAVM=f o &A— <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> 11 Restaurant: Searing CapacitySquare Footage <br /> Food Handlers Course required: Yes C3 No El <br /> C1 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 /> Color Type ype <br /> 11 Mobile Food Vehicle---Make VehicleSticker# <br /> Registration# License# <br /> Color <br /> T <br /> ype <br /> C1 Mobile Food Prep Unit--Make VehicleSlicker rc <br /> 11Registration# License# <br /> to Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from C1 Produce Stand <br /> ❑ Special Event - Dates of operation from LO <br /> DAIRY PROGRAM (2000) <br /> C1 Grade A Dairy ❑ Grade B Dairy C3 iVlilk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> 1-LAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator-------------------Tons Generated Per Year <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 /> ❑ Jail or Exempt Institution Number of Units <br /> C1 floteuivIotel-------Number of Units <br /> Employee Housing(2700) Use Employee Housinz/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> C1 Environmental Assessment C3UST-CAPSite ❑ Local 11W Cleanup Site C1NPL/SEP Cleanup Site [I UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ Natural Bathing Area <br /> Number of Pools/Spas at Facility C1 Pool ❑ Spa C1 out of Service Pool/Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Vehicle# <br /> C1 Pumper Vehicle—Registration# <br /> License# Capacity <br /> El Pumper Yard <br /> ❑ Package Treatment Plant 11Chemical Toilets—Numb.er of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> 11 Landfill C3 Transfer Station ❑ Ag/Cannery Waste Site <br /> ❑ /Recycle Facility <br /> [I CIA Landfill Site <br /> ❑ Waste Tire Facility [ICompost Facility Process ❑ Farm/Ranch Cleanup Site <br /> 11 Refuse Vehicles—Number of Units C1 Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care C3 Acute Care ❑ Skilled Nursing ❑ Large Generator El Small Generator ❑ Limited Hauler <br /> cilit <br /> C3 Transfer Station ❑ Veterinary Clinic <br /> E] Common Storage Fay — <br /> ❑ 2- IO ❑ I 1 -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON <br /> � Day Ph �9 � Night Ph <br /> FEE ❑ Surcharge FEE ❑ Other FEE <br /> PROGRAM EL 2 ❑ Food Handler�� <br /> INSPECTOR# PERMrr VALID tt <br /> Date INVOICE# ' <br /> ❑ Check# jILMOUNT PAID Date 3O�— <br /> ❑ Cash REVIEWED BY ACCCLr1 ING OFFICE Rev.07/07 99 <br />