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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT = MASTERFILE RECORD INFORMATION FORM _y N=ew ENew EH Program at Existing Facility _ ❑New EH Program and New Facility9�, Facility ID Program Record ID — JUN 201.9 Facility Address d�k-ft1 i-eu c R 15� ] SAN J (Please check the appropriate description and specify size, number of units and Pertinent information.) H4, IROpyt UIfy COAL Tv FOOD PROGRAM (1600) E MEN7- L 0. Restaurant: Seating Capacity __ Square !Dotage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only '❑ with Food Preparation ❑Vending Machines N tuber of Units 11 Retail Market----Square footage Elw/Meat Market only El Multiple Departments jn Prepackaged Goads Only ElMobile Food Vehicle --Make Vehicle Type 4' Color Registration # License # Sticker # ❑ Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # _ ❑ Temporary Food Facility --Dates of operation from to L Ice Plant ❑ Produce Stand ❑ Special Event---Dates of operation from to ❑CFO` ❑ A ❑`B DAIRY PROGRAM (2000) D. 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 El 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 LIST A and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ Hotel/Motel------Number of Units 'E7 Jail or Exempt Institution Number of Units Employee Housing (2700) Use Employee Hcuslnq/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-NPISEP`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 rnimber of birds 1:1 Kennel `TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) r.❑ Body Art Facllity-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility (4131) ,LIC UID WASTE PROGRAM (4200) _ ❑ "Pumper Vehicle Registration # License # _ Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ AglCannery Waste Site ❑ SludgelAsh Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site v❑,Refuse Vehicles (# 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 END 4fi-02-003 Blue Application Forr17 EMERGENCY NOTIFICATION FOR THIS FACILITYAND/OR PROGRAM CONTACT PERSON. ....... ✓ I IGrY"` �� Day Ph" 2=4 _�'�S � `�(%� Night Ph PROGRAM ELEMENT(` FEE_ ❑ Surcharge Fri ❑ Other FEE INSPECTOR# ^u! 4 w� lw✓IL PERMIT VALID' - j t0 ❑ Food Han ler ❑ Check #�_ '1AMOUNT PAID{, Z•$ }=� Date INVOICE ❑ Cash REVIEWED BY AccoumING OrFICC i ' Date 48.02.034 - w' / - 1/23113 f ? f „ f�IASTERFII E R CU♦?D INfURMATION PIN[(