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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Proqram at Existinq Facilitv []New EH Proqram and New Facilitv II Facilitv ID Program Record ID II Facility Address 1143y .fV1054� �2 11 , L 0 ("A q 521 -2, (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 P nt ❑ Produce Stand ❑ Special Event ---Dates of operation from to EYCFO ❑ 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 ❑ Hazardous Waste Generator (2200)-------> -Tons Generated Per Year ❑ Tiered Permitting Facility -----> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program ❑ Program 3 Facility ❑ PBR (2231) ❑ PBR HHW (2236) HOUSING PROGRAM (2400) ❑ Hotel/Motel ----Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee HousinglLabor 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 ❑ 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 # ❑ Pumper Yard SOLID WASTE PROGRAM (4400) License # ❑ Package Treatment Plant Capacity Vehicle # ❑ Chemical Toilets —Number of Units ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ SludgeftWLMte ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA ❑ Refuse Vehicles (# of Units) ❑ Dumpsters > 20 cu yd (# or Units) ❑ Farm Site MEDICAL WASTE PROGRAM (4500)y ❑ Primary Care El Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator L� jap er ❑ Transfer Station El Veterinary Clinic ❑ Common Storage Facility El - 10 ❑ 11 - AW> 60 leftors PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form h'Eq��RONMFC ((11 EMER NCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM ,0E/��'�Q CONTACT PERSONWaGt��A NN \ Q�M Day Ph 7- — ?,35-L� t�QNight Ph PROGRAM ELEMENT FEE FEE \5CJ ❑ Surcharge FEE ❑ Other FEE INSPECTOR # PERMIT VALID ❑ Check # AMOUNT PAID _ ❑ Cash Vida REVIEWED BY r c 1 ',f _ to ❑ Food Handler Date 221 2U INVOICE # ACCOUNTING OFFICE Date 482-32-034 00 -. 105�«58� MASTERFILE RECORD INFORMATION PINK