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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM C3New EH Program at Existing Facility ❑New EH Program and New Facili Facilit ID __ ___ _ Program Record ID Facility Address 7110 t "► e aJ B s 95 1D (Please check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) YES No /Q ❑ f$t Restaurant: Seating Capacity� Square Footage 'r Food Handlers Course required: ❑ 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 Vehicle Type Color ❑ Mobile Food Vehicle--Make License# Slicker# Registration# Color [I Mobile Food Prep Unit--Make Vehicle Type License# Sticker# Registration# ❑ ice Plant❑ Produce Stand ❑ Temporary Food Facility--Dates of operation from to ❑ CFO ❑ A ❑ B ❑ Special Event---Dales of operation from to 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) ❑ PBR (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) ❑ Jail or Exempt Institution ---Number of Uniis C1 Hotel/Motel-----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) C1 Environmental Assessment C1 UST-CAP Site 11 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) Number of Pcols/Spas at Facility 11 Pool ❑ Spa El out of Service Pool/Spa C1 Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Kennel ❑ Poultry Farm-------Maximum number of birds 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) License# Capacity Vehicle# ❑ Pumper Vehicle Registration# [I Pumper Yard C1 Package Treatment Plant ❑ Chemical Toilets--- Number of Units SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash a/Ash Site ❑ Landfill C3 Transfer Station ❑ AglCannery Waste Site 9 ❑ CIA Landfill Site C1Waste Tire Facility ElCompost Facility ❑ Process/Recycle Facility ❑ Farm/Ranch Cleanup Site ❑ Refuse Vehicles(a of Units) ❑ Dumpsters>20 cu yd (#of Units) MEDICAL WASTE PROGRAM(4500) 11 Primary Care ❑ Acute Care 11 Skilled Nursing El Large Generator [I Small Generator El 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 Farm ^ RGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Aow/ J Day Ph — /� Night Ph PROGRAM ELEMENT (� FEE 3/ro• ❑ Surcharge EE ❑ Other FEE 3/ ❑ Food Handler INSPECTOR# PERMIT VALID -7/ t0 -319-780 ❑ Check# AMOUNT PAID 37 OD Date 3d INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date -- MASTERFILE ECO D I FORMATION PINK qp m-n.14