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SAN JOAQUIN COUNTY L...VIRONIVIENTAL HEALTH DEPAR.,IENT MASTERFILE RECORD INFORMATION FORM JAN 2 0 2 015 New EH Program at Existing Facility Facility ID FA.c-f-. &%.) Program Record ID PRic6-7377 (=New EH Program and New Facility ENVIRONMENT HEALTH PERMIT/SERVICES Facility Address ‘, s6 A c/ (Please check the appropriate description and specify size, number of units and pa)tinent information.) FOOD PROGRAM (1600) Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ID No 0 El Commissary CI Dry storage only 0 with Food Preparation OVending Machines Number of Units 0 Retail Market----Square footage Li w/Meat Market only 0 Multiple Departments E Prepackaged Goods Only Li Mobile Food Vehicle --Make Color Registration # Mobile Food Prep Unit-- Make Registration # Temporary Food Facility --Dates of operation from Special Event---Dates of operation from DAIRY PROGRAM (2000) Grade A Dairy CU PA El Grade B Dein,/ CI Milk Dispenser-Number of Containers in Multi-Head Unit Hazardous Materials Business Plan (1900) Number of chemicals: Li CalARP Program 0 Program 1 Facility 0 Program 2 Facility D Program 3 Facility Hazardous Waste Generator (2200) > Tons Generated Per Year Tiered Permitting Facility > 0 CA (2232) Li CE (2233, 2234, 2235, 2237) 1:1 PER (2231) E PBR HHW (2236) El Aboveground Storage Tank Facility (AST) (2800) Number of ASTs Underground Storage Tank Program (UST) (2300) Use UST ,4 and B forms 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) Environmental Assessment E UST-CAP Site 1=1 Local HW Cleanup Site Li NPL/SEP Cleanup Site El UIC Site Li Abandoned HW Site Li non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site CI Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility 0 Pool D Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) Poultry Farm Maximum number of birds D Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) CI Body Art Practitioner Reg (4110) El Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) Body Art Facility-Sterilization (4121) D Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) Pumper VehicleRegistration # License # Capacity Vehicle # Pumper Yard Li Package Treatment Plant 0 Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) CI Landfill 0 Transfer Station Waste Tire Facility 12 Compost Facility Li Refuse Vehicles (# of Units) MEDICAL WASTE PROGRAM (4500) Primary Care E Acute Care 0 Skilled Li Transfer Station 0 Veterinary Clinic Li Ag/Cannery Waste Site Li Sludge/Ash Site Li Process/Recycle Facility El CIA Landfill Site Li Dumpsters > 20 Cu yd (# of Units) El Farm/Ranch Cleanup Site Nursing D Large Generator Cl Small Generator 0 Limited Hauler E Common Storage Facility 0 2-10 0 11 -60 El >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON / e- Day Ph (7(-)19) 2C1)2Li 5-9 Night Ph C:260 S- 7'/Y/ PROGRAM ELEMENT ELEMENT 433 FEE -4/P 0 Surcharge F E INSPECTOR # fP"-44441\ PERMIT VALID V to I 2-13 Food Handler AMOUNT PAID Date INVOICE # Date 0 Other FEE Li Check # Cash REVIEWED BY m -44-0,9-2,-- ACCOUNTING OFFICE 541/44- 48-02-034 1111/1 '1 MASTERFILE REC D INFORMATION PINK Vehicle Type License # Sticker # 2„2-c77 Vehitle Type Color License # Sticker # to Cl Ice Plant E Produce Stand to 0 CFO 0 A E B cA,14-