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SAN JOAQUIN COUNTY ' RRONMENTAL HEALTH DEPAR 'ENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID dv Program Record ID � k 46 Facility Address A'-P, 41k1-,� (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# lG if 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: ❑ CaIARP 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 EmploVee 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 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) Pd ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑,��i"�l� ' ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ Refuse Vehicles(#of Units) ❑ Dumpsters> 20 cu yd (#of Units) im/Ranceanup Site Q MEDICAL WASTE PROGRAM(4500) (', ( � 20 nn ❑ Primary Care El Acute Care El Skilled Nursing El Large Generator 11 Small &AlelptU� Li�ibd Hauler El Transfer Station 11 Veterinary Clinic El Common Storage Facility El1� B2- 10 ONA) W*nerators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Fonn DFpgRTME n EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM Hr CONTACT PERSON ^` "J �V�J ► G Day Ph ZU� '� Night Ph 1 y R 0(D PROGRAM ELEMENT FEE 2;5 (7DD ❑ Surca FEE ElOther FEE INSPECTOR# 2S PERMIT VALID t0 har2 O ❑ Food Handler ❑ Check\# AMOUNT PAID ` Date 2•D INVOICE# ❑ y Cash �45 1-) REVIEWED BY ACCOUNTING OFFICE Date S/Z 2-7 -D 1/23/1034 �. I ,, I O Irut � MASTERFILE RECO D INFORMATION PINK 1/23/13 �m`��_�'