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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM J4 New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID ^ — Prog ram Record ID Facility Address o2,&G al ledaLJ-)Ji )L 1-- CLL, C t l (Please check the appropriate description and specify izs e, number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating CapacitySquare Footage ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ Mobile Food Vehicle —Make Vehicle Type Registration # License #_ ❑ Mobile Food Prep Unit— Make Vehicle Type _ Registration # License #_ ❑ Temporary Food Facility —Dates of operation from ❑ Special Event --Dates of operation from to Food Handlers Course required: YES ❑ No ❑ ❑Vending Machines Number of Units ❑ Multiple Departments ❑ Prepackaged Goods Only Color Sticker # Color Sticker # to ❑ Ice Plant ❑ Produce Stand KCFOEIA❑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 ❑ 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-NPUSEP 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 VehicleRegistration # License # Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets --Number of Units SOLID WASTE PROGRAM (4400) P El Landfill El Transfer Station ElAg/Cannery Waste Site ft ite ❑ Waste Tire Facility El Facility ❑ Process/Recycle Facilitylite ❑ Refuse Vehicles (# of Units) ❑ Dumpsters > 20 cu yd (# of Units) „ (] Farm/RancCleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ SmaelQ�� ❑Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 1044 NZO generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form _'PARTjW NT 9 CONTACT PERSON Day P i % /�L'e) Night P ,>"C 9 )-02:2 " / 48 PROGRAM ELEMENT EE O ElSurcharge FEE El Other FEE INSPECTOR # g PERMIT VALID to 3 / %Z I ❑ Food Handler E�Check # 33yg AMOUNT PAID I� Date 2 2 INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE i Date 48-02-034 MASTERFILE RECOR IN ORMATION PINK 1/23/13