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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Pro ram at Existing Facility []New EH Program and New Facility Facility ID Program Record ID Facility Address 6j0"-33 V- i SS till 0 f. (�,-j (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 SYCFO ❑ A YB 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 ❑ 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 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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration # ❑ Pumper Yard SOLID WASTE PROGRAM (4400) License # ❑ Package Treatment Plant ❑ Kennel ❑ Body Art Facility -Single Use (4120) ❑ Body Art -Temp V13cility (4131) RECEIVED Capacity Vehicle # ❑ Chemical Toilets ----Number of •itil c Q20 Z- 1 'Vc ❑ Landfill ❑ Transfer Station❑ Ag/Cannery Waste Site S4IS��'"Z ❑ Waste Tire Facility❑ Compost Facility ❑ Process/Recycle FacilityI� ❑ Refuse Vehicles (#of units) ❑ Dumpsters > 20 cu yd (# of Units) "L7 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 ,7 _ CONTACT PERSON ( �"�Vf�`){'P��1 � �(� Day Ph-170-r>� �-77L Night PhZ- PROGRAM ELEMENT_ 1 iliL)L FEE ❑ Surcharge FEE ❑ Other FEE IN�PEJCTOR # � 2 B �� PERMIT VALID to // i ❑ Food Handler ❑Vh' O-Jo4 '15 1'�yAMOUNT6gPAID 'q 2 L E) — Date Z/ to �?/V 2,-C INVOICE # ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date IN 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13