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E <br />0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />lew EH Program at Existincgt Facility 'WNew EH Program and New Facility <br />Facilitv ID Q�23 ! Pro ram Record ID <br />Facility Address � � VtG\�\G kVV' 5tlx��t l �& �I520 <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 />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending 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 _ <br />Registration # License # Sticker # <br />❑ Temporary Food Facility --Dates of operation from to <br />❑ Special Event Dates of operation from to <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />Color <br />_ ❑ Ice Plant <br />❑ Produce Stand <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />❑ Hazardous Waste Generator -------Tons Generated Per Year ❑ Recycle/Exempt System (2299) <br />❑ CRT Offsite Handlers (2218) -------------❑ Silver Only (2222) ❑ Appliance Recyclers (2217) <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 />❑ Hotel/Motel ------Number of Units ❑ Jail or Exempt Institution --Number of Units <br />Employee Housing (2700) Use Employee HousinalLabor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) ^ Q <br />Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Are <br />VECTOR CONTROL PROGRAM (4000) V� h� <br />C1 Poultry Farm -----Maximum number of birds ❑Kennel �OJ�QY4 <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) �� e� � .; � <br />❑ Tattooing (4121) ❑Body Piercing (4120) Permanent Cosmetics (412 '/x, OJO- <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # License # Capacity Vehicle # AZ <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (# of Units) ❑ Dumpsters > 20 cu yd (# of Units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑Skilled Nursing I-] Large Generator ❑Small Generator 11 Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON <br />fl<itetxt S • IN <br />Day Ph <br />PROGRAM ELEMENT_ FEE 0L moi' M ❑ Surcharge F <br />INSPECTOR # ;JLZ-2 PERMIT VALID S 2t t0 30 <br />Check # AMOUNT PAID Date 3 21 <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE <br />48-02-034 <br />11/15/07 <br />Night Ph <br />❑ Other FEE _ <br />❑ Food Handler <br />INVOICE # <br />Date 3 2.L / <br />MASTERFILE RECORD INFORMATION PINK <br />