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L1SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility New EH Program and New Facility Facility ID d(�,2 Program Record ID Facility Address 1 —I okdiAmnetv Or, Lock LA cl SZ({ o (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) �J ElRestaurant: Seating Capacity_ Square Footage Food Handlers Course required: YES MI No ElElCommissary ElDry 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# Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event---Dates of operation from to ❑ CFO ❑ A)kB 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) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST) (2500) 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 Employee Housing/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 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 ❑ 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) GN� ❑ Pumper Vehicle Registration# License# Ca� Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical �}liat - mbe of Units SOLID WASTE PROGRAM(4400) 6�{i� � -o ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site 4�I N 6 dge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility OPQ\ptx 1 Landfill Site 00 ❑ Refuse Vehicles (#or units) ❑ Dumpsters> 20 cu yd In or U 0ja rm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) -0 ❑ Primary Care El Acute Care ❑ Skilled Nursing ❑ Large Generator L Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 1:12- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGE CY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON �wll I.l�ts 1 Day Ph-�o`) &a-ZzIa3NightPh X09 L(-8a-a�a3 PROGRAM ELEMENT C FEE `5t9'? '�l 9a ❑ Surcha ge EE El Other FEE INSPECTOR# /O PERMIT 1ALID t0 V3V111 ❑ Food Handler, I Check#x"153 AMOU TPAID�12CID Date �Z ( INVOICE# 3oq-341 ❑ Cash REVIEWED ACCOUNTING OFFICE Date 48-02-034 MASTERFILE R CO D INFORMATION PINK 1/23/13