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SAN JOAQUIN COUNTY ENVIRONRENTAL:HEALTH DIVISION <br /> MASTERFILE RECORD LNFOR�LATION FORM(EH 00 69) <br /> ❑ New EH Program at Existing Facility Ej ew EH Prograrn and New Facility <br /> Facili ID l iJ tf (, a-2, Program Record ID P RD 5 a I SD� <br /> FacilityAddress 153,3 C V'Vft frit c S-ft c-47ID-n Cl+ 952 5 <br /> (Please Check the appropriate description and specify size number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> Square Footage Food Handlers Course required: Yes ElNo C1 <br /> 11 Seating Capacity Sq ge <br /> C1 Commissary C3 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 /> Vehicle Type Color <br /> 11 Mobile Food Vehicle---Make Sticker# <br /> Registration# License,"t <br /> Vehicle Type Color <br /> C1 Mobile Food Prep Unit--Make Sticker# <br /> Registration# License# <br /> to ❑ Ice Plant <br /> C1TemporaryTemporary Food Facility--Dates of operation from F-1ProduceStand <br /> [ISpecial Event - Dates of operation from <br /> DAIRY PROGRAM (2000) <br /> C1 iVlilk Dispenser—Number of Containers in Multi-Head Unit <br /> 11 Grade A Dairy C3 Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) �22�1 -p II,Oak Ce <br /> WLZARDOUS WASTE PROGRAM(2200) <br /> C1 Hazardous Waste Generator --------------------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) Conditionally <br /> ei B alRu e Household Hazardous Waste <br /> ❑ Permit-By-Rule Fixed Unit y- <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 /> ❑ EloteUvlotel-------Number of Units <br /> mp rlpplicarion Form <br /> Employee Housing(2700) Use Employee HnusinZ/Labor Ca <br /> UNDERGROUND INJECTION CONTROL(3000) <br /> SITE MITIGATION(2900) <br /> C1 Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site LJ i`IPUSEP Cleanup Site El UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ Out of Service PooUSpa ❑ Natural Bathing Area <br /> Number of Pools/Spas at Facility ❑ 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(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle It <br /> C3 Pumper Vehicle-Registration# License# P ty <br /> C1 Pumper Yard <br /> C1 Package Treatment Plant C1 Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> El Landfill ❑ <br /> SA /Cannery Waste Site <br /> ❑ Transfer tation g El CIA Landfill Site <br /> ❑ Process/Recycle Facility <br /> C1 Waste Tire Facility C1 Compost Facility ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles-Number of Units ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Large Generator C1 Small Generator C1LimitedH� uo Sr <br /> 11 Primary Care 11 Acute Care ❑ Skilled Nursing <br /> C] Common Storage Facility —E] '-- 10 <br /> ❑ it -60—❑ 60, <br /> ❑ Transfer Station ❑ Veterinary Clinic <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS E90069 Blue Applicadon Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON <br /> Day Ph Night Ph <br /> ❑Surcharge FEE [I Other FEE <br /> PROGRA�r1 ELEMENT �u-7 FEE ❑ Food Handler <br /> PERMIT VALID to <br /> INSPECTOR# INVOICE# ` <br /> AMOUNT PAID Date <br /> ❑ Check# Date <br /> ❑ Cash REVIEWED BY ACCOuNrING OFFICE Rev.07/07/99 <br />