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r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT - MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facil4w ®New EH Program and New Facility _ Facili ID -.2 Program Record ID Facility Address 2612snoopD,I %sto ktm,GA (Please check the appropriate description and specify size number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity_ Square Footage Food Handlers Course required: YES❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market—Square footage ❑ with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit Make Vehicle Type Color Registration# License# Sticker# ❑Temporary Food Facility—Dates of operation from to ❑ Ice Plant ❑ Special Event Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy _ ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Mult-Head Unit CUPA ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)--------->-Tons Generated Per Year ❑ Tiered Permitting Facility----> ❑ CA(2232) ❑ CE(2233,2234, 2235,2237) ❑ PSR(2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST)(2800) Number of ASTs ❑ Underground Storage Tank Program(UST)(2300) Use UST A and B forms ❑Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel---Number of Units ❑ Jail or Exempt Institution----Number of Units Employee Housing(2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPVSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑Water 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(4100) ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art Facility-Single Use(412D) ❑ Body Art Facility-Sterilization(4121) ❑ Body Art Temp Event Coord(4130) ❑ Body Art-Temp Event Mobile Facility(41311 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 ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(9.f Unhs) ❑ Dumpsters>20 cu yd(#.f unae) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 011 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue AAolication Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Marshall Seavera,Plant Manager Day Ph 817o37-10 Night Ph 817-435-5025 PROGRAM ELEMENT_ FEE L -o• ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMITVAUD to ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY 2. ACCOUNTING OFFICE Date 4&02-034 MASTERFILE RECORD INFORMATION PINK 8/21/12