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' t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM El New EH Program at Existing Facility — []New EH Program and New Facility Facility ID Pro ram Record ID 43 4, D Facility Addresslove . Q U-41 ck� - k Ar" (Please Check the appropriate description and specify siz number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:.. YEs❑ No❑ ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines Number of Units ❑Retail Market----Square footage ❑with Meat Market only ❑Multiple Departments ❑Prepackaged Goods Only ❑Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# ❑Temporary Food Facility--Dates of operation from to ❑ Ice Plant ❑ Sp`cial Event --Dates of cpemtic:r fr.H!r_ to ❑Produce Stand DAIRY PROGRAM(2000) 13 Grade A Dairy [3 Grade B Dairy 13 Milk Dispenser---Number of Containers in Multi-Head Unit "CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200)" t ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle I Exempt System(2299) ❑CRT Offsite Handlers(2218) E]Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit By Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms HOUSING PROGRAM(2400) ❑Hotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units Employee Housing(2700)Use Fmplovee Housine/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. 13NPL/SEP Cleanup Site [3 UIC Site ❑Abandoned I1W Site 13non-NPLISEP Cleanup Site [3RWQCB Cleanup Site '❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number•of Pools/Spas at Facility. ❑Pool ❑Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area VECTOR.CONTROL PROGRAM(4000) (3Poultry Farm Maximum number of birds 11 Kennel ,_,,TT,oo,P—enY PIERCING PGI7141tARENT COSMETIC PROGRAM(4100) �'f1 ©1. . v Tattooing(4121) ❑Body Piercing(4120) Permanent Cosmetics t42 ) LIQUID WASTE PROGRAM(4200) El Pumper Vehicle Registration# License# Capacity Vehicle# ❑Pumper Yard lana- ❑Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑Sludge/Ash Site ❑Waste Tire Facility ❑Compost Facility ❑Process/Recycle Facility ❑ CIA•Landfill Site ❑Refuse Vehicles Number of Units ❑Dumpsters>20 cu yd Number of Units ❑Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4$00) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator E] Small Generator ❑Limited Hauler ❑Transfer Station ❑Veterinary Clinic ❑Common Storage Facility—Z] 2-10 ❑ 11-60-----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PIPS FHD 46-02-003 Blue Application Form EMERGENCY NOTIFIOATION FOR THis FACILITY ANDIOR PROGRAM CONTACT PERSON © 1 Day Ph — 9'.,'4(&3j Night Ph pRENT FEE 11 SurchargeFEE '" 13Other FEE IN$P OR# PERMIT VALID . to 11 Food Handler 11g AMOUNT PAID Date INVOICE# ❑ Cash REVIEWEDBY ACCOUNTING OFFICE Date ) W f l__._ll..D.........t D:..1.