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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ?TDInD Z_ MASTERFiLE RECORD INFORMATION FORM Cc ` � .New EH Pro rani at Existing Facility ❑New EH Program and New Fact iit L � Faclllt ID �/�o� Program Record ID C�S1 W Facility Address 171YO ncd-v Ua lt5372 (Please check the appropriate description and specify size,number of units and ue 1nent information.) FOOD PROGRAM(1600) C] Restaurant; Seating Capacity Square Footage Food Handlers Course required: YES ❑ NO ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units 5Wetall,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# 0 Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Produce Stand Ej Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM(2000) El Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA CO Hazardous Materials Business Plan(1900) Number of chemicals; ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility 0 Hazardous Waste Generator(2200)---------> Tons Generated Per Year PA EITiered Permitting Facility-------> ❑ CA(2232) 11 CE(2233,2234,2236,2237) ❑ PER(2231) 13PBR r1�1�4t �^(]' ❑ Aboveground Storage Tank Facility(AST)(2800) Number of ASTs ��CC ''/E� El Underground Storage Tank Program (UST)(2300) Use LISTA and B forms MAY❑ Other CUPA Program I O 2019 HOUSING PROGRAM(2400). `S'gNJO HOteUM0te1------Number of Units ❑ Jail or Exempt Institution----Number c� A_ QMQV �COOU/yn, Employee,Housing(2700) Use€mployee Housing/Labor Camp Application Fom) LTH pE-'PARTT EL SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) NT ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site Cl Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remedlation 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(4116) ❑ Body Art Facility-Single Use(4120) ❑ Body Art Facility-Sterilisation(4121) ❑Body Art Temp Event Co-ord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) Pumper Vehicle Registration# License# Capacity Vehicle# Ell Pumper Yard" ❑ Package Treatment Plant ❑ Chem ical Toilets----Number of Units SOLID WASTE PROGRAM(4400) El Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site 11 Waste.Tlre Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#or units) ❑ Dumpsters>20 cu yd(#of Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) Primary.bare'. ❑Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler I❑ Transfer.Station ❑.Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS END 46.02.003 Blue Application Form ERGE NOTIFICATION FOR THfs FACILITY AND/OR PRO RAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT _, FEE ❑ Surchar'g F E IJ Other FEE INSPECTOR# //{I`.:L: PERMIT VALID Jr—ZD to �� ❑ Food Handler ❑ Check#---' AMOUNT PAID �D U� Date � INVOICE# 3Z Cash REVIEWED 6Y ACCOUNTING OFFICE Date S� 48-02-094 ` MASTERFILE RECORD IN ORWIATION PINK "' 1 2T1