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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existln Facili New EH Program and Naw Facility <br /> Facility ID��}� �J Program Record ID _ <br /> Facility Address I�ui "��� �� 5�1C'E )IQ A, �� QJ30L - <br /> r <br /> (Please check the appropriate description and specify&,number of unit and go^lmint information.) <br /> p P <br /> FOOD PROGRAM(1600) NO <br /> Restaurant: Seating capacitySquare Footage Food Handlers Course I:pLICCd: YOU <br /> umber of Units <br /> Commissary Dry storage only with Foody araLOO A:IjR Vending Machines <br /> N <br /> Retail MarkeL_Square footage 3,,000 w/Meat Market only Multiple Departments Prepackaged Goods On <br /> ly <br /> Mobile Food Vehicle-.Make Vehicle Type _ Color fJ fa <br /> Registration# License# Slicker# <br /> Mobile Food Prep Unit-Make Vehicle Ty,. Color 0 I¢ <br /> Registration# License# Sticker# <br /> Temporary Food Facility_Dates of operation from <br /> to Ice Plant Produce Stand <br /> Special Event—Dales of operation frons - to CFO A B (-J 1 <br /> 141 <br /> DAIRY PROGRAM(2000) <br /> Grade A Dairy Grade S Dairy Milk Dispenser-Number of Containers in Mutts-Head Unit_ N A <br /> CUPA Fe Yx P= [ Ls( <br /> Hazardous Materials Business Plan(1900) Number of chemicals: Cog Ie.SP�I 0 C 1 <br /> CalARP Program Program 1 Facility Program 2 Facility Program 3 Facility <br /> Hazardous Waste Generator(2200)--->_Tons Generated Per Year 0 I}\ <br /> Tiered Permitting Facility—> CA(2232) CE(2233,2234,2235,2237) PBR(2231) PBR HHW(2236) <br /> Aboveground Storage Tank Facility(AST) (2800) Number of ASTs Z. <br /> Underground Storage Tank Program(UST)(2300)Use UST A and R forms <br /> Other CUPA Program <br /> HOUllING PROGRAM(2400) N)A <br /> HotellMotel_­Number of Units Jail or Exempt Institution-­Number of Units <br /> Employee Housing(2700)Use Employee Hnuslno1Z_abQLf&WgAgWjgjlLlQU Form <br /> gUE MITIGATION(2900) ^^ROUND 1N IECTION bGROL(3000) <br /> Environmental Assessment UST-CAP Site ^Local HW Cleanup She NPLISEP Cleanup Site UIC Site <br /> Abandoned HW Site non-NPL/SEP Cleanup Site RWQCB Cleanup Site Water Quality Remedlatlon Site <br /> grCgEATIONAL HEALTH PROGRAM(3600) <br /> Pool Spa Out of Service Pool/Spa Natural Bathing Area <br /> Number of Pools/Spas at FacilityN <br /> VECTOR CONTROL PROGRAM(4000) ^, <br /> Kennel <br /> Poultry Farm-__-Maximum number of birds <br /> I v <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> Body Art Practitioner Reg(4110) Mechanical DSPS Notification (4115) Body Art FacilitySingle Use(4120) �� <br /> Body Art Facility-Sterilization(4121) Body Art Temp Event Cord (4130) Body Art-Temp Event Mobile Facility(4131) <br /> �uID WACTE PROGRAM(4200) <br /> Re istration# i icense# Capacity Vehide# IA <br /> Pumper Vehicl 9 (-I <br /> Pumper Yard Package Treatment Plant Chemical Toileta__.Numbw of Unite <br /> cnr rD WASTE PROGRAM(4400) <br /> Landfill Transfer Station Ag/Cannery Wast*Site Sludge/Ash Site P <br /> Waste Tire Facility Compost Facility Process/Recycle Facility CIA Landfill Site <br /> Refuse Vehicles(#of Units' Dumpsters>20 cu yd(#of Unna+ Farm/Ranch Cleanup Site <br /> MEDICAL uIASTA pgoaR_ AM(4500) <br /> Primary Care Acute Care Skilled Nursing Large Generator Small Generator Limited Hauler N <br /> Transfer Station Veterinary Clinic Common Storage Facility 2-10 11 -60 >60 generators <br /> pl rpi Ic WATER SYSTEM PROGRAM(4600)Use PWS"'^46-02^03 Blue Aoolication Form <br />