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ft <br /> ffSANJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTEIMLE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility ONew EH Program and New Facility JUN 2 <br /> 9 2010 <br /> Facilit ID <br /> Program Record ID �1 �/�QVUE.NT HEALTjj <br /> Facility Address k5"5'4 A-A-6 0 Lt r2 P S 6 Ct=-�/ `i S Z'4 ii'jSERV/CES <br /> (Please.Check 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 11 N013 <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Fending 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 /> 13Temporary 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(2219) ❑ Silver Only(2222) ❑Appliance Reeyclers(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 Rousing(2700)Use Employee Kousinz/Ldbor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(30W) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site <br /> 11Abandoned MY Site 13 non-NPL/SEP Cleanup Site 13RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Pool ❑Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR.CONTROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birds ❑Kennel <br /> T 00 BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> Tattooing(4121) ❑Body Piercing(4120) [3 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 ❑CIALandfill Site <br /> ❑Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd----Number of Units ❑Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator D Small Generator ❑Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--0 2-10 ❑ 11-60------❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PH'SEMD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM <br /> CONTACT PERSON F (_--i.E\(s E04- r__1ADay Ph ;L-7 t- $ Night Ph <br /> PROGRAM ELEMENT 41?-[ FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# 3173 PERMITVALID to ❑Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED By G-0 e)3-2— ACCOUNTING OFFICE Date <br /> P M Vinl <br />