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4 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> j MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Programat Existing FaclIq ❑New EH Program and New Facili <br /> j_Facility ID ri(; ? 7 Program Record ID S �a 'y <br /> facility A-dares-, 70 3 (.t Ly J 15 j,--' 0 51"bnt-m GQ t 5'X2 <br /> (Please check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant Seating CapacitySquare Footage Food Handlers Course required: Yes❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market—Square footage ❑w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to lceRant❑ Produce Stand <br /> ❑ Special Event—Dates of operation from to FO A ❑ B <br /> DAIRY PROGP4m rave.=. <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Mutt-Head Unit <br /> CUPA <br /> ❑ Hazardous Materials Business Pian(1900) Number of chemicals: <br /> ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator(2200)-->-Tons Generated Per Year <br /> ❑ Tiered Permitting Facility--> OCA(2232) ❑ CE(2233,2234,2235,2237) ❑ PBR(2231) ❑ PBR HHW(2236) <br /> L'1 Aboveground Storage Tank Facility(AST)(2600) Number of ASTs <br /> ❑ Underground Storage Tank Program(UST)(2300) Use UST A and B/bmrs <br /> ❑Other CUPA Program <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteliMotei—Number of Units ❑Jail or Exempt Institution---Number of Units <br /> Employee Housing(2700)Use Employee HousinNLabor Camp Appiica0on Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑NPL]SEP Cleanup Site 0 UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Podis/Spas at Facility _ ❑Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number of birds ❑ Kennel <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art Facility-Single Use(4120) <br /> ❑ Body Art Facility-Sterilization(4121) ❑Body Art Temp Event Coord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑Chemical Toilets—Number of Units <br /> 3011D WASTE PROGRAM(4400) �. <br /> ❑ Landfill ❑Transfer Station ❑ AglCannery Waste Site 13SludgelAgh SEet <br /> El Was Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Land��f6P, _ 6 <br /> ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd(s or units) 11Faff "Q��rnch u <br /> MEDICAL WASTE PROGRAM(4500) y PV O'Q4& <br /> 11Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 [111-60 ❑ > <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHO 4602-003 Blue Application Form NT <br /> ENERGENc NOTIFICATION FOR THis FACILITYAND/OR PROGRAM <br /> CONTACT PERSON Day PhD9 220 �i Night Ph 26iQ`.170 <br /> PROGRAM ELEMENT FEE JU ❑ Surcharge Fee 11 Other FEE <br /> INSPECTOR# PERMIT VALID t0 ❑ Food Handler <br /> ❑ Che # AMOUNT PAID i Date T 2 INVOICE# <br /> UJCaVtL REVi VHMME ElyS ACCOUNTING OFFcE Date <br /> 48-02-034 A Ccou nl �,TI��gO�� elfrff/�II FPeS MPSTERRIE RE <br /> CORD kNFORWT=PEW <br /> 1123113 ApPilieq 1Z3 pet, <br /> ins/ieCic✓` <br />