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SAN JOAQUIN COUNTY EN ONMENTAL HEALTH DEPART T <br /> MASTERFILE RECORD INFORMATION FORM o <br /> 11 New EH Program at ExistingFacility ew EH Pro and New Facility JAN 2 3 2012 <br /> Facility ID <br /> Program Record ID <br /> ENVIRONMENT HEALTH <br /> Facility Address S L4 NM U J �' !z 1,621)1 �l S 2GCZ7 PERMIT/SERVICES <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:. Yrs❑ No❑ <br /> ❑Commissary13Dry storage only [Iwith Food Preparation ❑Fch <br /> ending Maines 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 ❑Milk Dispenser---Number of Containers in Multi-Head Unit <br /> CUPA ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) d <br /> ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle f 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 UST A 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 Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 11 Environmental Assessment ❑UST-CAP Site 11 Local HW Cleanup Site, 11NPLISEP Cleanup Site 11 UIC Site <br /> ❑Abandoned HW Site ❑non-NPUSEP Cleanup Site ❑RWQCB Cleanup Site '❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Pool ❑Spa ❑Out of Service PoollSpa ❑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(4121) 11 Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> C]Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑Pumper Yard ❑Package Treatment Plant- ❑Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑Transfer Station ❑Ag I Cannery Waste Site ❑Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑Refuse Vehicles Number of Units ❑Dumpsters>20 cu yd Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care . ❑Acute Care ❑ Skilled'Nurs'ing ❑Large Generator Q Small Generator ❑Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑Common Storage Facility-----❑ 2-10 ❑ 11-60------❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWSEHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM i <br /> CONTACT PERSON Day Ph �. Night Ph � Z.®0 1 <br /> PROGRAM ELENT t Z FEE Aj ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# 19 PERMIT VALID . to ❑Food Handler <br /> i <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date f <br /> Masterfile Record Pink <br />