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LA./ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFiLE RECORD INFORMATION FORM C IP New EH Program at Existin Facility ❑New EH Program and New FaciRy C 0S+C-.'3 Faclllt ID �Facilty Ads S C g5z1� e ' e (Please check the appropriate description and specify size, number of units and pertinent information) ✓ FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units �etall 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# Slicker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM.(2000) PAYIWEIV r Ell Grade A Dalry_, El Grade B Dairy El Milk Dispenser-Number of Containers in Multi-f{ ►k.•- 1® CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: Q� ❑ CalARP Program Ell Program 1 Facility El Program 2 Facility 171 Program 3 Facility Z 0 2019 ❑ Hazardous Waste Generator(2200)----------> Tons Generated Per Year SAN JOAQUIN ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE(2233,2234,2235,2237) ❑ PBR(2231) 1�0"g N71' ❑ Aboveground Storage Tank Facility AST 2800 Number of ASTs TFl DEPART L 9 9 y( )( ) MENT El Underground Storage Tank Program (UST)(2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ Hotel/Motet•-- -Number of Units ❑ Jail or Exempt Institution----Number of Units EmMoyee.Hous(ng(2700) Use Employee Housing/Labor Camp Application Foml 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-NPL/SEP 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 number of birds ❑ Kennel TATTOO 606Y PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification (4116) ❑ Body Art Facility-Single Use (4120) El 13ody.Art Facility-Sterilization (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# ❑ Pumper.Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLIDIVASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ElAgiCannery Waste Site 1:1Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site El Refuse Vehicles(#of Units) ❑ Dumpsters> 20 cu yd(#of Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Caro ❑Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 -10 011 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS END 46.02-003 Bluo Application Form E RGE C NOTIFICATION FOR THIs FACILiTYANO/OR PRO RAM CONTACT PERSON O ICI L Day PhZT4 52Ct535 Night Ph PROGRAM ELEMENTJibFEE ElSurchar a F7E� El Other FEE INSPECTOR}P.. S PERMIT VALID to Sal w ❑ Food Handler ❑ Check# AMOUNT PAID Date S INVOICE# ❑ Cash REMEVYED.BY ACCOUNTING OFFICE Date SZ _ t/231131 / R4ASTERFILE RECO DIN tO ORtJI N PINK 1!23113 �'//