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SAN JOAQUIN COUNTY I HEALTH DEPAR NT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility ❑New EH Program and New Facility . Facilit ID FPr DDD 5q 3g Program Record.ID Facility Address IIy3 1 Rft,tAn, St- (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 ❑ w/Meat Market only ❑ Multiple Departments❑ Pre ckaged Goods Only 13 Mobile Food Vehicle—Make Vehicle Type Cc r Registration# License# Stick # ❑ Mobile Food Prep Unit--Make VeHide Type Color Registration# License# Sqfcker# ❑ Temporary Food Facility—Dates of operation from /FacilitO ❑ Ice Plant❑ Produce Stand ❑ Special Event---Dates of operation from toCFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Diontainers in Multi-Head Unit_ CUPA 11 Hazardous Materials Business Plan(1900) Number of chemicals: CaIARP Program ❑ Program 1 Facility El Program gratn 3 Facility Hazardous Waste Generator(2200)------> Tons Generated Per Ye9)l❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE (2233,2234BR((31) ❑ PBRHHW(2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number ofAST ❑ Underground Storage Tank Program (UST) (2300) Use UST RUST A ams ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ Hotel/Motel—Number of Units Cl Jail or Exempt Institution----Number of Units Employee Housing (2700) Use Employee Housing/Labor CamD Anolication Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Loc HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEPZOGMS(4100) to ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility_ ❑ Poolpa ❑ Out of Service Pool/Spa . ❑ Natural Bathing Area,. GRAM 4000 VECTOR CONTROL PRO ( ) ❑ Poultry Farm------Maximum number of birds ❑ Kennel ' TATTOO BODY PIERCING PERMANENT COSMETIC ❑ Body Art Practitioner Reg (4110) ❑ Mec anical DS PS Notification (4115) ❑ Body Art Facility-Single Use(4120) ❑ Body Art Facility-Sterilization(4121) ❑ ody Art Temp Event Co-ord (4130) [] Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ P kage Treatment Plant ❑ Chemical Toilets--Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transf Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Com ost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(*of units) ElDumpsters>20 cu yd (#of units) ElFarm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4 0) ❑ Primary Care ❑ Ac a Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ V terinary Clinic ❑ Common Storage Facility 112-10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM ROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERS c Day Ph Night Ph PROGRAM ELE ENT Z2� FEE d r ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMITVALID I)) IL4 toI �/3i� ❑ Food.Handler ❑ Check# AMOUNT PAID� Date INVOICE# El Cash REVIEWED BY 'v/ ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13