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r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION ORM PAYIWENT 11New EH Program at Existing Faciliq SdNew EH Program and New Facility RIECEIVIE0 Facility ID Program Record ID ��'� . . � w�c��. (Wel AR �� 2077 Facility Address IJ 0 Z SANJOAQurnrCO (Please check the appropriate description and specify size,-number of units and Pertinent information.) N -ENVIRONMENr�L Tx. FOOD PROGRAM(1600) ALTy DEPART�t=1YT I ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: 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 Registration# License# Sticker# i ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker 1# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event---Dates of operation from to 55-CFO n�A ❑ B 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: j ❑ 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) ❑ PBR(2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use USIA and B forms - 11 Other CUPA Program HOUSING PROGRAM(2400) ❑ HotellMotel----Number of Units ❑ Jail or Exempt institution----Number of Units Employee Housing (2700) Use Employee Housing& bor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site= ❑ NPUSEP Cleanup Site ❑ UIC Site #. ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) I� Number of Pools/Spas at Facility ❑ Poo! ❑ 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) j LIQUID WASTE PROGRAM(4200) ❑ Pumper VehicleRegistration#. 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 i ❑ Refuse Vehicles V of units) ❑ Dumpsters>20 cu yd (#of units) ❑ Farm/Ranch 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. ❑ 2 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM i' CONTACT PERSON )?]]/Lc " Day Ph -C—(.&;-767 ight Ph } PROGRAM ELEMENT � � 0 ) FEE h ❑ Surcharge FEE ❑ Other FEE INSPECTOR# b z! , PERMIT VALID t0 i ❑ Food Handier. Check# AMOUNT PAID Date 3/7 7„ INVOICE# ❑ Cash REVIEWED BY C{ M ACCOUNTING OFFICE Date 46-02-034 U MASTERFILE RECORD INFORMATION PINK 1/23113 i