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SAN�OAQUIN COUNTY IRONMENTAL HEALTH DEPA ENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility Z1 New EH Program and New Facilit Facilit ID 07 1 011 Program Record ID 70rfi6a Facility Address 6H `I VE (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) Food Handlers Course required: YES ❑ No ❑ 11 Restaurant: Seating Capacity_ Square Footage ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market----Square footage ❑ w/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# Slicker# to 11 Ice Plant O Produce Stand 11 Temporary Food Facility--Dates of operation from [I CFO ❑ A 11 B 11 Special Event---Dates of operation from to DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit_ CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ 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) ❑ PER(2231) ❑ PER 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 El Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Emolovee Housino/Labor Camp Aoolication Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) 11 Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site LINPL/SEP Cleanup Site [1 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) ❑ Kennel ❑ Poultry Farm-------Maximum number of birds TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) Capacit Vehicle# [I Pumper Vehicle Registration# License# Y ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM (4400) ❑ Sludge/Ash a/Ash Site C1 Landfill L1 Transfer Station 11Ag/Cannery Waste Site g ❑ ProcesslRecycle Facility ❑ CIA Landfill Site 11 Waste Tire Facility El Compost Facility El Farm/Ranch Cleanup Site ❑ Refuse Vehicles(#orunus) EIDumpsters>20 cu yd (#or units) 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 ADpllcation Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM Day Ph Night Ph CONTACT PERSON L7 El Surcharge FE [I Other FEE PROGRAM ELEMENT FEE � ❑ Food.Handler INSPECTOR# PERMIT VALID L �G. to a 11 check u 3 AMOUNT P ID Date INVOICE# Date ' 11 Cash REVIEWED 8Y�V r"' I J b (u ACCOUNTING OFFICE MASTERFILE RECORD IN OR TION PINK 48-02-034