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4 <br /> I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> IVI'Vew EK Program at Existinz Facility ❑Nett/Ell.Program and New Facility <br /> Facilit •ID I'ro ram Record ID Q-n Si2gfl , <br /> rae City Addre s ai � _ -� = <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 /> [3Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines—Number of Units <br /> 13 Retail Market—Square footage ❑with Meat Market only 11Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Mobile Food Prep Unit--Makc 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 /> v CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200)" i <br /> 11 Hazardous Waste Generafor. Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2216) ❑ Silver Only(2.222) ❑Appliance Recyclers(224 7) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit By Rule Fixed Unit D 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 /> Ii0[JStNG PROGRAM(2400) - <br /> ❑Hotd/Motel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Houslag(2700)Use Fmployee Housine/Labor Camp Applicatran Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> .1] Environmental Assessment ❑UST-CAP Site ❑Local IIW Cleanup Site. ❑NPLISEP Cleanup Site ❑WC Site <br /> ❑Abandoned HW Site ❑non-NPLISEP Cleanup Site ❑R\VQCB Cleanup Site "D Water Quality Remediation Site.' <br /> RECREATIONAL"EALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility [3Pvol 13 spa [3 Out of Service Poo <br /> llSpa [3 Natural Bathirsg Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> 13 Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooing(4 121) 0 Body Piercing(4120) ❑Permanent Cosmetics{4122) <br /> LIQUID WASTE PROGRAM(4200) 00"�C <br /> :�Iimper Vehicle—Registration <br /> # LE / Capacity Vehicle.# <br /> ❑Pumper Yard ©Package Treatment Plant" ❑Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑ Transfer Station ❑Ag 1 Cannery Waste Site 13Sludge/Ash Site <br /> ❑Waste Tire Facility 11 Compost Facility ❑ Process/Recycle Facility ❑ CIA-Landfill andf I!Site <br /> ❑Refuse Vehicles--Number of Units ❑Dumpsters>20 cu yd Number of Units ❑FarrivIiaach Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑Large Generator 0 Small Generator ❑ Limited Hauler <br /> ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-----O 2-10 © 11-60------0>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use FWS EHD 46-02-003 BlqeAp2licirtian Form <br /> r=MFRGCNCY NOTIFICATION FOR TIi15 FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON 2X Day Pham � 7�T3 Night Ph <br /> PROGRAM ELEMENT 4FEE o—o 0 SurchargekFsE'-. ❑ Other FEE <br /> INSPECTOR# S3Lle - PERMITVALID 0T_ to L3f 3t�a�r ❑Food Handler <br /> ❑ Che-k# <br /> AMOUNT Date 1-2-11 D� INVOICE# <br /> Cash R6VIEWEDBY ACCO[iIiTII�GOFFICE __Date l <br />