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SAN JOAQUIN COUNTY.ENVIRONIVIENTAL HEALTH DEPARTMENT I T-jyfVkENT MASTERFIL-E RECORD INFORMATION FORM F?ECE �,dErl ❑ New EH ProMay `� gram at Existing Facilit New EH'Pro ram and New Facility . 1 2016 Facilitv ID Program Record ID SA,4 jDAQUIt4 COU14TY Facility Addressl7 tv� 1, [ C Q HEALTH ID PAR-rMij l� (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 refired_ YES ❑ No ❑ ❑ 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 l Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates'of operation from to ❑ Icc as El Produce Stand [I Special Event---Dates of operation from to CFO !i A E 6 DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ Hazardous Materials Business Pian (1900) Number of chemicals: ❑ CalARP Program ❑.Program 1 Facility ❑ Program 2 Facility El 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 LISTA and forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotellfiotel-----Number of Units ❑ Jail or Exempt Institution----Number of Units Employee Housing(2700) Use Employee Housinq/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site f ❑ Abandoned HW Site ❑ non-NPLISEP 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 i ❑ Kennel 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) ❑ 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 1:1Sludge/Ash Site El Waste Tire Facility ❑ Compost Facility C1Process/Recycle Facility ❑ CIA Landfiil Site ❑ Refuse Vehicles (#of units) ❑ Dumpsters>20 cu yd (#of Units) ❑ FarmlRanch Cleanup Site MEDICAL WASTE_PROGRAM(4500) _ 13 Primary Care .. El 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 A_egficaffon Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM ONTACT PERSON \- s.2} 2� Cqs �P ,74 Soo Ani Day Ph _ Night Ph. A 2. PROGRAM ELEMENT L0'01 FEE 41 -01 ❑ Surcharge FEE ❑ Other FEE INSPECTOR# b PERMIT VALID r� to El Food Handier o? Check# r 6 _� U A NT PAID 570 JG Date_ S /rI //b INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE I Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 1123113