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R�C� T RECEIVED SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT JUIV 08 2009 MASTERFILE RECORD INFORMATION FORM SANJOAQUINCODNn, ❑ New EH Program at Existing Facility ❑New EH Program and New Facility Hf= L-I-H DEp T�7Vl NT Facility ID � D 0 D4 LI 43 Pro ram Record ID h 9-n 0 4 Facility Address SqS a G• I,-�r3 cc� 1'Le� ! -c�a ►�.�w C�4- qS�z- (Please check the appropriate description and specify size, number of units and pertinent 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 1; 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 Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) -------------11 Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility -------------------❑ Conditionally Authorized (CA) ❑ Conditionaily,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 LISTA and B forms i HOUSING PROGRAM(2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housin /Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP 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 k ❑ Kennel TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) LIQUID WASTE PROGRAM(4200) F ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ AglCannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of Units) ❑ Dumpsters> 20 cu yd(#of Units) ❑ FarmlRanch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler D Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Applicali_on Form EMERGENCY NOTIFICATION FOR THIS FACILITYANDIOR PROGRAM CONTACT PERSON SI S r eCA,jb!L_� Day Ph 36 _ Night Ph PROGRAM ELEMENT 42-qZ FEE ISC7O. &'D ❑ Surcharge FEE I-] Other FEE INSPECTOR# 5&&4 PERMITVALID 4a 19 / 0 '� y to ?> () I 10 ❑ Food Handier 2 `Check# q C 1 AMOUNT PAID �� 4 O, D Date $ 4 K&- INVOICE#01 11Cash REVIEWED BY ACCOUNTING OFFICE Date (} 48-02-034 MASTERFILE RECORD INFORMATION PINK 11/15107