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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Pro ram at Existing Facility ftNew EH Program and New Facility Faci I i ty ID H 60555— Program Record ID (Z Facility Addres '51[2-1 17�� Vll V L: C S" ^iCll ✓► C �� (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 ❑ 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 Q-tFO 21�❑ B DAIRY PROGRAM (2000) ❑ 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 ❑ 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 UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing(2700) Use Employee Housing/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-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 L ❑ Refuse Vehicles I#of Units) ❑ Dumpsters>20 cu yd(#of Units) ❑ Farite MEDICAL WASTE PROGRAM(4500) CC �I viEn ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator I ited Hauler ElTransfer Station El Veterinary Clinic El Common Storage Facility El - 10 El 11 -60 - 01g"V ors PUBLIC WATER SYSTEM PROGRAM 4600) Use PWS EHD 46-02-003 Blue Application Form SAN JOA �+ ( EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM HEAL IRONMFN UNTy CONTACT PERSON'\FF : O Vl r, C�V Day Ph ��2 —fib S -12�S )Night Ph H DEPA TAS PROGRAM ELEMENT l n FEE ElSurchar a FEE 11 Other FEE INSPECTOR#>J 1 PERMIT VALID to 1�3� Z� ❑ Food Handler ❑ Check# AMOUNT PAID (S5, Date 1 D 21 INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE A9 , Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13