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SAN JOAQUIN COUNTY ERMONMENTAL HEALTH DEPAR <br />MASTERFILE RECORD INFORMATION FORM <br />DrNew EH Program at Existing Facility ❑New EH Program and New Facility <br />H) <br />Record ID <br />Facility Address W, 1 o'4 ST . T,E09 C `/1 C19 9.53 74- <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 />11Commissary 11Dry 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 Color <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 />❑ Ice Plant <br />❑ Produce Stand <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser --Number of Containers in Multi -Head Unit <br />COPA ❑ 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 DSTA 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 Cama Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ 1; IC site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM <br />VECTOR CONTROL PROGRAM ? ? ^? <br />■ <br />TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM <br />LIQUID WASTE PROGRAM <br />❑ Puniner -r ._.avucity <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets -------Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site <br />❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ CIA Landfill Site <br />❑ Refuse Vehicles --Number of Units ❑ Dumpsters > 20 cu yd —Number of Units <br />❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ---❑ 2 - 10 --- <br />❑ 11 - 60 ---❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EMD 46-192-007 /' •- <br />EMERGENCY NOTIFICATION FOR THts FACILITY AND/OR PROGRAM <br />57EVQj BOLOek-S (ZO7) 0/4- 4?781, <br />-09) 832-25.3- <br />❑Surcharge FEE <br />13 <br />INSFEL MR # YLKMI I V ALllJ to <br />❑ r uou itanuier <br />❑ Checkft AmouNT PAID Date <br />INVOTCF # <br />❑ Cash RrVICVITD B <br />j <br />Date <br />48-02-034 <br />Masterfile Record Pink <br />1 Uibi2003 <br />