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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM p E,(v -0 New EH Pro ram al Existin Facility ❑New EH Program and Ni Facility R 2 01 Facilit•ID �D �gs� Pro ram Record ID J k'! Sa AUG `)+ I acilify Address 3 -c-t ( C, 7� ✓✓_' S N `� -; 2 (/ SAN JOA®NIMEN P- (Please Check the appropriate description and specify s-izg number of units and pertinent information.) HATH oeppR'fMENT FOOD PROGRAM(1600) Restaurant: Seating Capacity Z D Square Footage Food Handlers Course required: Yrs 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 ❑ lee 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 Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) / ❑Hazardous Waste Generator. Tons Generated Per Year _ ❑Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(221 s) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit-By-Rule,Fixed Unit ❑Permit-By-Rule Household Hazardous Waste ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms HOUSING PROGRAM(2400) ❑ Ilotel/Motel Number of Units ❑jail or Exempt Institution—Numbs Of Units Employee Housing(2700)Use Fmplope+71ousine/Labor Camp Application Form SITE MITIGATION(2900) - UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site ❑ Abandoned IIW Site ❑non-NPLSEP Cleanup Site ❑RWQCB Cleanup Site -❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ P991 ❑Spa ❑Out of Service POOVSpa ❑Natural Bathing Area VECTOR. ONTROL PROGRAM(4000) ' ElPoultry Farm—Maximum number of birds 11 Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) 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-Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑Farm/Rauch 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--O 2-10—1111-60--❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PHSF.RD 46-02-003 Blue ApaUcadon Form 1_MERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON .S' /"t G k k-Ja-r4 Day Ph Li - - Night Ph PROGRAM ELEMENT FEE - 2-20 ❑ Surcharge FEE ❑ Other FEE INSPECTOR# DlI PERMTTVAUD .9,fW 0 n to 31 U0 ❑ Food Handler- [I fandler -S• ❑ C-Leetril! AhIOUNT PAID Date 0''I INVOICE# ❑ Cash IZEVIEWEDBY lJ r/UJ ACCOUNTING OFFICE Date S O