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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD"INFORMATION FORM <br /> New EH Program and New Facility <br /> 11 New EH Pro at ExistingFacility 1N c;C�u <br /> ,/�,� / SAN JCVIRaN"��i��P�N1 <br /> Facilit. ID YIT U I g s Pro rant Record lD PRO 5�-(P 9 F OFP SME <br /> Facility Address 9 2 6 w. Prewert: Load La thrta A 95330 <br /> H <br /> TN <br /> (pleCheck the appropriate description and specify s <br /> ase number of units and pertinent information) <br /> FOOD PROGRAM(1600) <br /> O Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YES❑ No 11 <br /> ❑ Commissary ❑Dry storage only ❑with Food Preparation ❑Fending Machines Number of Units <br /> 11 Retail Market----Square footage [3 with Meat Market only 11 Multiple Departments ❑Prepackaged Goods Only <br /> ❑Mobile Food Vehicle---M"ake Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Mobile Food Prep Unit-Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> E3Temporary Food Facility----Dates of operation from to 13 ice Plant <br /> Q 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 Q State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200)' 1 <br /> ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> Q CRT Offsite Handlers(2218) Q Silver Only(2222) Q Appliance Reeyclers(2217) <br /> Tiered Permitting Facility-------- ❑Conditionally Authorized(CA) ❑Conditionally Exempt(CE) <br /> Q 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 UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑Rotel/MotelNumber of Units 13 Jail or Exempt institution Number of Units <br /> Employee Housiag(2700)Use Emplevee Housinz/Uber Camp Applicaflort Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑Environmental Assessment Q UST-CAP Site ❑Local HW Cleanup Site, Q NPLISEP Cleanup Site ❑UIC Site <br /> Q Abandoned HW Site ❑non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑'%Vater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. Q PQot ❑Spa Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR.COHTROL PROGRAM(4000) <br /> 13 Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> Q Tattooing(4121) Q Body Piercing(4120) 13 permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑Pumper Vehicle Rogistration# License# Capacity Vehicle-# <br /> [3 Pumper Yard ❑Package Treatment Plant. ❑Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill Q Transfer Station ❑Ag/Canuery%N aste Site ❑Siudge/Ash Site <br /> ❑Waste Tire Facility Compost Facility ❑Process/Recycle Facility ❑CIALandfill Site <br /> ❑Refuse Vehicles Number of Units ❑Dumpsiers>20 cu yd Number of Units ❑Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> [J Primary Care ❑Acute Care ❑ Skilled Nursing Large Generator [7 Small Generator Q Limited hauler <br /> 13 Transfer Station ❑Veterinary Clinic [3 Common Storage Facility-0 2-10 E311-60 -❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EMD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM <br /> CONTACTPERSON Den Oliver DayPh209 334-a3659 Night Ph 209 466-0605 <br /> PROGRAM ELEMENT _q! � FEE (qo ❑ Surcharge FEE ❑Other FEE <br /> INSPECTOR# PERMIT VALID to (. 3(I.U-7 ❑Food Handler <br /> 11Check# AMOUNT PAID 1$I ?0- 00 Date �1, I o"1 INVOICE# <br /> 0 Cash REVIEWED BY l�U��"�y23b-jLf ACCOUNTING OFFICE �; Date <br />