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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at ExistIng Facility []New EH Pr ram and New Facility Facility ID 170 2 f Program Record ID 4�S 76) Facility Address 1273 N_,_ MftiN S` rn fCAI q CE) (Please check the appropriate description and specify size,numb r 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 Mending 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 Plant O Produce Stand C1Special 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- 2M ❑ 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- 13 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 Emulovee Housing/Labor Camn Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTBOL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site 0 RWQCB Cleanup Site ❑Water Quality Remedlation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL P13QGRAM(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 Faclllty-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# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Faclllty ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd(#or units) ❑ FarmlRanch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS END 46-02-003 Blue A1 ca o Form EMERGENCY N TI ICATiON FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON-M ONACA FI Ln 6 0 Day Ph 2LOi Night Ph PROGRAM ELEMENT FEE L' ❑ Surchar a FE 13Other FEE INSPECTOR# __,s�7 _ PERMiTVALiD 13 w t0 30 20 ❑ Food Handler ❑ Check# AMOUNT PAID Date Q INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 3 49-02-034 MASTERFILE RE ORD IWORMATION PINK 1123!13