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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility - []New EH Program and New Facility Facility ID �aa 25��0� Program Record ID �5�ZJ2 Facility Address C�_ (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) Ig Restaurant: Seating Capacity 1� �:) Square Footage Food Handlers Course required: YES 1 No El L'bommissary El Dry storage only 1:1 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 ❑ CFO ❑ A ❑ 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: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Prograrn 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 Housinq/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) ❑ Purnper Vehicle Registration# License# Capacity Vehicle# ❑ Purnper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of UnP SOLID WASTE PROGRAM (4400) Nei ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Slu ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ /� andfill� ❑ Refuse Vehicles (#of Units) ❑ Dumpsters> 20 cu yd (#or Units) ❑ f atiil'lR r h�,lf� Site MEDICAL WASTE PROGRAM (4500) 19ANJOA / �U ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small GeI�R 47ipuler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 10 ❑ 11 6 O�gjt %enerators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Fonn EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON m\_tC ret irr Rl c 1 ,c Day PhlZ929)3 21-2,012 Night Ph (2pal 321- ZO l2 _ ( PROGRAM ELEMENT ` CJ� FEE 1' ❑ Surchr e F E El Other FEE { I� INSPECTOR# ` g PERMIT VALID to 218 ❑ Food Handler / {{ N Check# AMOUNT PAID .� Date INVOICE# 3 y ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date J 48-02-034 MASTERFILE RECOR6 INFORMATION PINK 1123/13