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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT �� 3�ZI MAS T ERFILE RECORD INFORMATION FORM tew EH Program at Existing Facility ❑New EH Program and New Facility y NT Facility ID S Program Record IDlk VeD Facility Address221��d°"7 OCj 11 18 (Please check the appropriate description and specify size, number of units and pertinent information.) `S"J FOOD PROGRAM (1600) N E TI�ROHM COU ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course re reci:OTT - Commissary ❑ Dry storage only Ith Food Preparation ❑Vending Machines Number of Units (❑ Retail 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# ❑ 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) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit COPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility pw ❑ Hazardous Waste Generator(2200)----------> Tons Generated Per Year y ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE (2233,2234, 2235, 2237) ❑ PBR(2231) ❑ PBR' �► ❑ Aboveground Storage Tank Facility (AST) (2800) Number ofASTs ��/G+?� Fo ❑ Underground Storage Tank Program (UST) (2300) Use USTA and B forms S,, ❑ Other CUPA Program /y, F/O,gQU/ ?O19 HOUSING PROGRAM (2400) TyRONM CO(� ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution ----Number of FHq�,_Tq V Employee Housing (2700) Use Employee Housing/Labor Camp Application Form FHT 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, 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) ❑ 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 (#of units) ❑ Dumpsters> 20 cu yd (#or 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 EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON �1 Day Ph Night Ph PROGRAM ELEME T V FEE '3o ❑ SurchafIpe fEE ❑ Other FEE INSPECTOR#�ti` RMIT VALID 6" t0 >'. /.z�3 /1 ❑ Food Handler ❑ Check# :; AMOUNT PAID 30 .b� Date ?-d! INVOICE# ❑ Cash REVIEWED BY, ACCOUNTING OFFICE Date 48-02-034 ^ J 19 q ? �j/ MASTERFILE RECORD FORMATION PINK 1/23/13 L-IJ�L /537, ( O