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t 1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT AUG 2 9 2007 <br /> MASTERFILE RECORD INFORMATION FORM <br /> 11 New EH Pro at ExistingFacility ew EH Program and New Facility <br /> ^�NVIPipNMENT HEALTH. <br /> Facilit•ID D ' Pro ram Record ID It t°�' �� �S p�RM�TI$�RVICES <br /> Facility Address3'746 y1 ,-ntne /' -LA-4 . s rz f 25-If v <br /> (Please.heck 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 ❑with Food Preparation DA-'ending 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(20W) <br /> ❑Grade A Dairy ❑Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) 3 <br /> ❑Hazardous Waste Generator- Tons Generated Per Year O Recycle/Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) C1 Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility13 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 Eerplovee VousinzTabor Camp AWlication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local BW Cleanup Site. E3NPL/SEP Cleanup Site 13UIC Site <br /> 13Abandoned HW Site 11 non-NPL/SEP Cleanup Site 13RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility [I P901 13 Spa [3 out of Service Pool/Spa 11 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 /> It Tattooing(4121) WBody Piercing(4120) ❑Permanent Cosmetics(4122) <br /> LIOUID 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 11 Transfer Station 13 Ag!Cannery Waste Site, <br /> ❑ Studge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ProcesslRecycle Facility ❑CIA•Landfill Site <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 ' ❑Acute Care ❑ Skilled Nursing ❑Large Generator [7 Small Generator ❑Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--[] 2-10 ❑ 11-60-----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS E1fD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FAC4LITY AND/OR PROGRAM <br /> CONTACT PERSON C,� �2/Q Vic r r 'P2 Day P / Night Ph <br /> PROGRAM ELEMENT L(2.0�`f "�— ❑Surchar a FEE ❑ Other FEE <br /> INSPECTOR# G PERVALID to ❑Food Handler <br /> ElCheck# AMOUNT PAID Date INVOICE# <br /> 0 Cash REV IENVED BY 0_0 03 Z-- ACCOUNTING OFFICE Date a V <br />