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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT {I MASTERFILE RECORD INFORMATION f ORM , i�V LSD t ❑ New EH Program at Existing Facilit New EH Program and New Facility c� MAX 0 8 2017 Facility 1D nD-0 6 Program Record ID Ms41(aq f ENVIRONMENTAL HEALTH Facility Address mack I v- 1?r PERMITISERVICES (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 recce: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units 11Retail Market----Square footage ❑ w/Meat Market only ElMultiple Departments ElPrepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color €� Registration# License# Sticker# 41 ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# tl ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ 13- DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi=Head Unit COPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: i ❑ CalARP 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) D PER(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 EmMovee Housing/Labor Cama Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) il Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) I ❑ 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 U17 se (4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event M bile 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) i 1:1 Landfill 13 Transfer Station 1:1Ag/Cannery Waste Site ElSludgelAsh Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles t#of units) ❑ Dumpsters> 20 cu yd (#of units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) f ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑,Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 0 n 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD_46_-02-003,Blue Application Form MERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT ltdo FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# _ ]�j 20 PERMIT VALIDC� "� " t0 3 3 1` El Food Handler ©-Cfieck &4L.,.► AMOUNT PAID F—X-f— ►1fA Date 3 Q INVOICE# 1. ©-C.a h REVIEWED BY IM ACCOUNTING OFFICE Date 3 48-02-034 Y MASTERFILE RECO D'INFORMATION PINK' '1!23!4 3 1 i _ f