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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM �l <br /> LF r`iew EH Program at Existing Facility ❑Ne\r) EH Program and New Facility <br /> I, Facility IO <br /> Facility Address 27 4p f Mmer Avg'--5 �1n ca y-&-aK <br /> (Please check the appropriate description and specify size. number of units and pertinent information.) <br /> FOOD PROGRAM (1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market----Square footage ❑ wlMeat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant ❑ Produce Stand <br /> ❑ Special Event---Dates of operation from to [] CFO ❑ A ❑ E <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CU-PA <br /> S - <br /> X Hazardous Materials Business Plan (1900) Number of chemicals: <br /> ❑ CalARP Program ❑ Program 'I Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator (2200)----------> Tons Generated Per Year <br /> ❑ Tiered Permitting Facility-------> ❑ CA (2232) ❑ CE (2233, 2234 2235. 2237) ❑ PBR (2231) ❑ PBR HHW 122361 <br /> ❑ Aboveground Storage Tank Facility (AST) (2800) Number of AST s <br /> ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br /> ❑ Other CUPA Program <br /> HOUSING PROGRAM (2400) <br /> ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution ----Number of Units <br /> Employee Housing (2700) Use EnlploVee Housing/Labor Camp Application Form <br /> SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site - ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM (3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM (4000) <br /> ❑ Poultry Farm-------MlaxinnJm number of birds ❑ Kennel <br /> TATTOO, BODY PIERCING.PERMANENT COSMETIC PROGRAM (4 100) <br /> ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) <br /> ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility (4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units <br /> SOLID WASTE PROGRAM (4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles (=o`units? ❑ Dumpsters> 20 cu yd n c.r units: ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM (4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 - 60 ❑ > 60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PVVS EHD 46-02-003 Blue Application Fant <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> C014TACT PERSON Day Ph Night Ph <br /> Ii PROGRAM ELEMENT �"12-� FEE �p <br /> El Surcharge FEE El other FEE <br /> INSPECTOR# PERMIT VALID Q / t0 ❑ Food Handler <br /> ❑ Check AMOUNT PAID [�(�` ;24>2-0 Date IN / I E# <br /> ❑ Cash RE\IE1'.'ED 6_ —_--A,I:OI)NTING OFFICE -- -- — Date 9z �_ _ <br /> 1-.STET FILER CO ,L,IFiF.F1,1. TI!rJ Pt'Jf — _. <br />