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0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART!ENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New Ell Program at Existing Facility ❑New EIi Program and New Facility <br /> Facility ID A program Record ID 53 IL I <br /> Facility Address 1�,t19,b �-}ali�ti l�1 L <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Reslauraat: Seating CapacitySquare Footage Food Handlers Course required:. YEs❑ NO❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation 11 Vending 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 /> ❑ 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) l <br /> ❑hazardous Waste Generator Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Reeyclers(221 7) <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 B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotenlotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee I10usiag(2700)Use EmployeeOousinKgbor Camp Applica(ien Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAF Site ❑Local HW Cleanup Site, ❑NPLfSEP Cleanup Site 11UIC Site <br /> ❑Abandoned 11W Site [Inon-NPLISEP Cleanup Site ❑RWQCB Cleanup Site '❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑P®ol ❑ Spa ❑Out of service PoollSpa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> [I Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑Body Piercing(4120) ❑ 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 13 Transfer Station V Ag f Cannery`Paste Site ElSludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ProcesslRecycle 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 /> 0 Primary Care ' ❑Acute Care ❑ Skilled'Nurs'mg ❑Large Generator D Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—[] 2-10 ❑ I1-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use Pff'SFfID d6-02-003 BlacApplica(ion Form <br /> EMERGENCY NOTIFICATION FOR THis FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph _ <br /> PROGttAht ELEMEN IT LAA l9 + FEE ❑ Surchar eFEE - ❑ Other FEE <br /> INSPECTOR# -- PERMIT VALID 11!I_ to j 1 ❑ Food Handler <br /> C1 C beck t AnzOurrr 1'�.I _ �1 t -�'��— 'Date t 1 (I 1 INVOICF# <br /> Cash REVIEWED BY�� Nil ACCOUNTING OFFICE _ bate --- <br />