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SAN JOAQUIN COUNTY ENVILONMENTAL HEALTH DEP <br /> ARTR <br /> Am <br /> MASTERFILE RAID INFORMATION FORM 4� <br /> 13 New EH Program at Existing Facility ❑New EH Program and Nese Facility <br /> Facility IDf� Up j Z Program Record ID R-O <br /> Facility Address ,2­43S (,tJe,/�� <br /> (Please Check the appropriate description and specify size,number orunits and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:.. YEs❑ No ❑ <br /> ❑ Commissary ❑Dry storage only ❑with Food Preparation ❑Vendiag 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 ❑Milts Dispenser--Number of Containers in Multi-Head Unit <br /> L CUPA ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) i <br /> ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle 1 Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) 0-Silver Only(2222) -. ❑Appliance Recyclers(2117) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑Conditionally Exempt(CE) <br /> ❑Permit-By Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste <br /> ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑,HoteUMotel Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employee Housing/Labor Camp Appficadert Form _ <br /> ;n_ <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> •❑ Environmental Assessment ❑UST-CAP Site ❑Local RW Cleanup Site ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned H`NV-Site ❑non-NPUSEP Cleanup Site ❑RWQCB Cleanup Site ❑NYater Quality Remediation Site -` <br /> RECREATIONAL HEALTH PROGRAM 3600 <br /> Number of Pools/Spas at Facility_ ❑Pool ❑Spa ❑Out or Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR,CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooing(4,121) ❑Body Piercing(4120) ❑Permanent Cos 4122) ` <br /> LIQUID WASTE-.PROGRAM(4200) <br /> ❑Pumper Vehicle—Registration# License# Capacity vehicle. <br /> ❑Pumper Yard ❑Package Treatment Plant• ❑Chemical Toilets Number of nits <br /> SOLID WASTE PROGRAM(4400) <br /> 13 Landfill $Tra 3 on ❑Ag/Cannery\Waste Site 13 Sludge/As Site <br /> Tire Facility ❑Com ost Facility ❑Process/Recycle Facility ❑CIA-Landfill Site <br /> IMELDICAL <br /> Vehicles—Number of units Dumpsters>20 cu yd---Number of Units ❑Farm/Ranch Cleanup Site <br /> WASTE PROGRAM,4500 <br /> 4fi <br /> ❑ Primary Care ' ❑Acute Care U Sldlied'Nursing ❑Large Generator 13.Small Generator ❑Limited hauler <br /> ❑Transfer Station ❑.Veterinary Clinic ❑Common Storage Facility-0 2-10 [3111-60----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UsePWSEHD 46-02-003 Blue Annlica(ion Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT 4 2 3 FEE ❑Surcharge FEE ❑ Other FEE <br /> INSPECTOR# .73 77"`1 PERMIT VALID t 1, U0 to &Ubfij ❑Food Handier - <br /> ❑alk# ; AMOUNT P4,m Date INVOICE# Z! 0 D Z <br /> Cash REVIEWED BY AO 0 ACCoumiNG OFFICE ate �Z VO <br />