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SAN JOAQUIN COUNTY ENSVRONMENTAL HEALTH DEPART NT MASTERFILE RECORD INFORMATION FORM IQ-New EH Program at Existing Facility ❑New EH Pro am and New Facili Facility ID 5 Program Record ID Facility Address S 5 2, G cfa _ (Please Check the appropriate description and specify size,number of u is and erti t 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 ❑ Special Event --Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Mufti-Head Unit COPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) ❑ SiIver Only(2222) E] 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 USTA and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel-----Number of Units ❑Jail or Exempt Institution Number of Units Employee Housing(2700)Use Employee HousM /Labor eamp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL 3000) ❑ Environmental Assessment ❑UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site © UIC Site ❑ Abandoned HW Site ❑non-NPL/SEP Cleanup Site ❑ RWQCB 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) ❑ Poultry Farm Maximum number of birds ❑ Kennel TATTOO,BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) XML*— ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200),WV Sr AA N;q gj� y�-�.,� )-Pumper Vehicle--Registration# License# iS 7.Zav Capacity 7 ti g Vehicle# RD 13 Pumper Yard 11 Package Treatment Plant ❑ Chemical Toilets-------Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag 1 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(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----❑ 2-10-------011 -60------❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT —lY� FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR#f Ghia ly-:5 ;�RMIT VALID to ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE ` Date 48-02-034 Masterfile Record Pink 1016/2003