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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTEIMLE RECORD INFORMATION FORM r <br /> ❑New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facilit•ID KP <br /> -gram ram Record ID < 11 <br /> Facility Address Q L441 rCkinn` �.9 'Skk <br /> (Please Check the appropriate description and specify siz 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 ❑N'endiag 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 /> n Sial E'reat --Dates of opeemfion 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 /> , <br /> nit CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200)" 1, <br /> 13 Hazardous Waste Generator" Tons Generated Per Year 11 Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑Silver Only(2222) ❑Appliance Recyclers(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/MotelNumber of Units 11Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee Housine/Labor Camp Application Form <br /> SITE MITIGATION(2900) - UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local RW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site 4❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑P901 ❑Spa ❑Out of Service PooUSpa ❑Natural Bathing Area <br /> VECTOR"CONTROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birds ❑Kennel <br /> •FATToo,QrnnY PIERClk'G,PERM. ANENT COSMETIC PROGRAM(4100) <br /> ;0 Tattooing(4121) ❑Body Piercing(4120) Permanent Cosmetics k412 <br /> LIQUID WASTE PROGRAM(4200) - <br /> 11 Pumper Vehicle Registration# License# Capacity Vehicle•# <br /> ❑Pumper Yard _ ❑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 ❑ CIA-Landfill Site <br /> ❑Refuse Vehicles Number of Units ❑Dumpsiers>20 cu yd Number of Units ❑Farw/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑Skilled Nursing ❑Large Generator 11 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 PF!'SEAD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFIG TION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph, C($d j {(j Night Ph ^7tC1"1- <br /> PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> INsY OR _ PERMIT VALID to 11Food Handler <br /> El AI110UNT PAID Date INVOICE# <br /> 13 Cash REVIEwEi BY ACCOUNTING OFFICE Date 1 1 <br />