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SAN JOAQUTIN COUNTY ENVIRONMENTAL HE,ALTH DEPARTMENT MASTERFILE RECORD-INFORMATION FORM ANew EH Program at Existing Facility E3 New EHnnProgram and New Facility Facitif ID $'S� Program Record ID T 0 S3 b f Facility AddrensS X51 Qa a 'e. Ave (Please Check the appropriate description and specify size•number of units and pertinent information.) FOOD PROGRAM(1604) ❑Restaurant: Seating Capacity Square Footage Food handlers Course required:. Yrs❑ No ❑ ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Fending Machines—Number of Units ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ElMobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑Mobile Food Prep Unit—Make Veliicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility----Dates of operation from to ❑ Ice Plant 11Special Event —Dates of operation from to 11 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) ❑ Silver Only(2222) ❑ Appliance Reeyclers(2217) Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit-By Rule Fixed Unit ❑Permit-By-Rule Household Hazardous`haste ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms HOUSING PROGRAM(2400) ❑ Hotel/6fotel Number of Units Jail or Exempt Institution Number of Units Employee housing(2700)Use Fmployee HousinerlLabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local 11W Cleanup Site- ❑NPLISEP Cleanup Site ❑UIC Site ❑Abandoned 11W Site ❑non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑`Vater 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 ❑Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4104) ❑ Tattooing(412 1) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant- ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ProcmfRecycle Facility 11CIA•LandfIll Site ❑P.efuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd Number of Units ❑Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑Skilled'Nursing Large Generator Cl Small Generator ❑ Limited Ilauler ❑Transfer Station ❑Veterinary Clinic ❑ Common S orage Facility----[] 2-10 ❑ I l-60--❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4604)Use PIVS FHD 46-02-003 Blue Applica[ion Form E=MERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM CONTACT PERSON Day Ph Night Ph — i PROGRAM ELE1l1EIr'T 4SjC) FEE 11; ❑ Surcharge FEE'- ❑ Other FEE _ INSPECTOR# -- PERMIT VALID . to �z�3� �� ❑ Food Handler ❑ Check t, MIOUNT PAID ?kLZ)Gb bate INVOICE# oft 4$�` ❑ Cash 1'�EVIEWED BY 6E ACCOUNTING OFFICE — - Date