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- - --- --- 5!Z C)0'y �vv SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM _ co New EH Program at Existing Facility ❑New EH Program and New Facility FaProgram Record ID Facility Address _ 9�' Z!D -Q- I � (Please check the appropriate description and specify size,number of units and pertinent information.) rJr�-rti,� ✓U� FOOD PROGRAM(1600) El Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units :15�1<etail Market---Squaro 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 El Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000); ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Hea6%�I ��p. CU PA EC�t 1 El Materials Business Plan (1900) Number of chemicals: ��® ❑ CaIARP Program _ ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility �0'9 MAY 2 ❑ Hazardous Waste Generator(2200)----------> Tons Generated Per Year I u Q;Tiered Permltting Facility-------> ❑ CA (2232) ❑ CE(2233,2234,2235,2237) ❑ PBR (2231) ❑"�P6WE/VOf 2 36 Aboveg ound orage Tank ty 2800) Number f ASTs ElUndergrround Sttorage Tank Progria m((UST)((2300) Use UST A and B forms HEALT�OEPA MEAir El Other CUPA Program T HOUSING PROGRAM (2400) ❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing(2700) Use Employee Housing/Labor Camp Application Farm 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-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remedlatlon 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 (41'15) ❑ Body Art Facility-Single Use (4120) ❑ Body Art Faclllty-Sterllization (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 SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles I#orunils) ❑ Dumpsters> 20 cu yd(#ol units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTQ PROGRAM(4500) ❑ Primary Care ElAcute Care ElSkilled Nursing EILarge Generator ElSmall Generator El Limited Hauler ❑ Transfer.Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS ENA 46-02-003 Blue Application Form E RGENc NOTIFICATION FOR THIS FACILITY AND/OR PRO RAM CONTACT PERSON O IG�U K ) Day Ph-7( S211-535Y Night Ph - PROGRAM ELEMENTFEE EJSurchar e F E El Other FEE INSPECTOR#C--1 PERMIT VALID t0 S / ❑ Food Handier ❑ Check#_ AMOUNT PAID UV Date S / INVOICE#I• 3 Z ❑ Cash REVIEWED BY ACCOUNTING OFFICE _Date S 48-02-094 n�� MASTERFILE RECORD4NFO MATION PINK 1/23.!13 �`J /