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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Pro ram and New Facilit Facilit ID ; A 6D�a� Pro ram Record ID Facility Address-1;30 -5 . �c I'l `�" 1� 5-7, � (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 E],Retail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only jq Mobile Food Vehicle--Make Vehicle Type Color Registration# License# f 1 :Zl '] 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 ❑ 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 Housing/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 Fp%cility(4131) LIQUID WASTE PROGRAM (4200) I � � ❑ Pumper Vehicle Registration# License# Capacity Vehicl �r ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) f / ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Slu Site '?019 ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ C � El Refuse Vehicles (#of Units) ElDumpsters> 20 cu yd (#of Units) El Farm �f f4te MEDICAL WASTE PROGRAM (4500) pARrMFiyT ❑ 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 EDARGENcy NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM 1 CONTACT PERSON Ke611 7� 1 III '1 Day Ph n 6 I Night Ph&V •Li1�Q PROGRAM ELEMENT �� FEE --x.23 1 ❑ Surcharge FEE 1:1 1:1Other FEE INSPECTOR# I9 �PERMIT VALID i I I q to ' 3I l L� ❑ Food Handler ❑ Check# 'b&Lf AMOUNT PAID Date I It j INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE XV16V Date l 48-02-034 MASTERFILE RECORD NFORMATION PINK 1/23/13