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SAN JOAQUIN COUNTY E RONMENTAL HEALTH DEPAR1 NT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility I:New EH Program and New Facility R PAYAIENT eceveo ri(2/- DM p Program Record ID 1)-aS--(7Q-14-77? DEC 2 9 2017 Facility Address 23-i-1 F_A5 .1--- 51- ) ru c_l_ CP q55 -2 1-,e'slialvs yliv couNry (Please check the appropriate description and specify size, number of units and pertinent information.) HEALTH DuEIEt I y_TAL FOOD PROGRAM (1600) lVpMAi NT Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES CI No 0 Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units Retail Market----Square footage CI w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only Ef Mobile Food Vehicle --Make Vehicle Type Color Registration # License # .;','v 7, Sticker # Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand CI Special Event---Dates of operation from to CI CFO CI A 0 B Facility ID DAIRY PROGRAM (2000) Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit CUPA CI Hazardous Materials Business Plan (1900) Number of chemicals: El CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility CI Hazardous Waste Generator (2200) > Tons Generated Per Year CI Tiered Permitting Facility > CI CA (2232) CI CE (2233, 2234, 2235, 2237) 0 PBR (2231) CI PBR HHW (2236) CI Aboveground Storage Tank Facility (AST) (2800) Number of ASTs Underground Storage Tank Program (UST) (2300) Use UST A and B forms CI Other CUPA Program HOUSING PROGRAM (2400) Hotel/Motel Number of Units CI Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) CI Environmental Assessment 0 UST-CAP Site 0 Local NW Cleanup Site 0 NPL/SEP Cleanup Site CI UIC Site CI Abandoned NW Site El non-NPL/SEP Cleanup Site CI RWQCB Cleanup Site 0 Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility CI Pool 0 Spa 0 Out of Service Pool/Spa CI Natural Bathing Area VECTOR CONTROL PROGRAM (4000) CI Poultry Farm Maximum number of birds CI Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) CI Pumper Vehicle Registration # License # Capacity Vehicle # 0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) CI Landfill CI Transfer Station El Ag/Cannery Waste Site 0 Sludge/Ash Site Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site Refuse Vehicles (# of Units) El Dumpsters > 20 cu yd (#01 Units) 0 Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) Primary Care 0 Acute Care CI Skilled Nursing CI Large Generator 0 Small Generator 0 Limited Hauler CI Transfer Station CI Veterinary Clinic CI Common Storage Facility CI 2 - 10 0 11 - 60 0 > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY •TIFICATION FOR THIS FACIL TY AND/OR PROGRAM CONTACT PERSON (i‘lrY\ Day Ph 2--c)(t 2.(:/Night Ph (T2_069 PROGRAM ELEMENT I It" FEE 4t We° Surch.ar e FE CI Other FEE INSPECTOR # PERMIT VALID 2/ 't/ to V 0 Food Handler _ CI Check # AMOUNT PAI (, Date INVOICE # 9 5 REVIEWED By ACCOUNTING OFFICE Or Cash Date it 8-02-034 MASTERFILE REC D INFORMATION PINK 1/23/13