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Y <br /> i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD-INFORMATION FORINT <br /> ❑New EH Pro am at Existing Facility New EH Program and New Facility <br /> Facitif ID DD a-1 p 17, __Program Record ID r we 5-3 `o <br /> Facility Addres'si`i�¢0 Hat�u n Lct��t��. CA X533 <br /> (Please Check the appropriate description and specify sizenumber of units and pertinent information) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage Food Handlers Course required:- YI;s❑ NO ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market s-•-Square footage ❑with Meat Market only ❑ Multiple Departments ❑Prepackaged Goods Only <br /> ElMobile 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(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser Number of Containers in Multi-Bead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) f <br /> ❑hazardous Waste Generator.!- Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> [3CRT Offsite Handlers(2218) [1Silver Only(2222) F1 Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By Rule Fixed Unit ❑Permit-By Rule Household Hazardous.`Vaste <br /> ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and Pi forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteUMotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> E€nployeeIfousing(2700)Use EmployeeAousinKabor Camp Application Foram <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 13 Environmental Assessment ❑UST-CAF Site 11 Local MV Cleanup Site, L1NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned IIW Site ❑trop-NPIJSEP Cleanup Site ❑R.WQCB Cleanup Site ❑Nater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility- ❑Pool ❑ Spa ❑Out of Service PoolJSpa ❑Natural Bathing Area <br /> VEGTOR.GONTROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birds 11 Kennel <br /> TATTOO BODY PIERCING PERMANENT CO•SMETIG PROGRAM(4100) <br /> ❑Tattooing(4121) ❑Body Piercing(4 120) ❑ 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 ❑ CIA•Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑ Dumpsfers>20 cu yd—Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑Skilled Nursing ❑Large Generator El Small Generator Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--[] 2-10 ❑ 11-60--- >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UsePff'SE fD f6-02-003 ElucApplicalion Form <br /> EMERGENCY NOTincATiON FOR THis FACILITY ANO/Ort PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> �5 '7_ FEE - - <br /> PItOGR.4AiELE14iElVT � / / ❑ Surchar eF E�. El FEE _ <br /> INSPECTOR# — PERMIT VALID ."711 11 1 ( to 1-1,131 ❑ Food Handler_ <br /> ElChcck t _ AINIOUNT PAID lr Date INVOICE#�1 .--- <br /> ❑ Cash REVIEWED BY �l ACCOUNTIII s JFFICE Date <br />