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y <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD"INFORMATION FORM <br /> New EH Program at Existing Facility [I New EH Pro&=and New <br /> --Facility <br /> Facilit •ID _Program Record ID 5_0 <br /> JJry y <br /> Facility Address ZHO Fn Ymcyif- AiA-- <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❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑N'eadiag 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 it 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(2000) <br /> ❑ Grade A Dairy ❑Grade B Dairy ❑Milk Dispenser Number of Containers in Multi-Head Unit <br /> GUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) f <br /> ❑Hazardous Waste Generator:---Tons Generited Per Year ❑Recycle[Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) [1Silver Only(2222) ® Appliance Reoyclers(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 fornits <br /> HOUSING PROGRAM(2400) <br /> totenjotel Number of Units 11 jail or Exempt Institution Number of Units <br /> [I I <br /> Lmptoyee housing(2700)Use Employee'Yousine/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site 11 Local HAV Cleanup Site. 11NPLISEP Cleanup Site 11 UIC Site <br /> ❑Abandoned TINY Site ❑ non-NPLISEP Cleanup Site ❑R`VQCB Cleanup Site ❑`rater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility- ®1'001 ❑ Spa ❑Out of Service PoollSpa ❑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 /> ❑ Tattooing(4121) ❑Body Piercing(4 120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> 11 Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> 11 Pumper Yard ❑Package Treatment Plant. ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> El Landfill E] Transfer Station 13 Ag I Cannery Waste Site ❑Sludge/Ash Site <br /> ElWaste Tire Facility ❑ Compost Facility 11 FrocesslRecycle Facility ❑ CIA•Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑FarmlRanch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled'Nursing XLarge Generator ❑ Small Generator ❑Limited Hauler <br /> ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--11 2-10 ❑ l l-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIVSEAD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FORTH(s FACILITY ANOIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph — <br /> PROGR.4AIELEMEI T�C�_ iT �-1 ❑SurchargeFEe . ❑ Other FEE <br /> INSPECTOR# — QZU PERMIT VALID_�, ,�_ t0 y 'a l 11 Food Handler_�y <br /> 11 Ghcck f AI1fOUAiT 1'.4113 �s 1_L t, _ bate INVOICE# /� -1 a s3—— <br /> El Cash [L_EVIEWFD IIx ""� '�' -- ACCOUNTING OFFICE Date 3 ZZ 11 <br />