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Vay.11-2020 21:54 x0133 P 2 C�Rn HOD SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID I Pro ram Record ID Facility AddressIN- 1 � �tI,1,)A (Please check the appropri to description and specify slze, n her of units and pertinent In rmation.)r FOOD PROGRAM(1600) ❑ Restaurant Seating Capaci Square Footage Fool Handlers Course required: YES) No ❑ El Commissary ❑ Dry storage only ❑ with Food Preparation ❑V�nding 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 ElProduce Stand ElSpecial 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 Cl Program 2 Facility, ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)--->-Tons Generated Per Year ❑ Tiered Permitting Facility- > ❑ CA(2232) ❑ CE(2233, 2234, 2235,237) ❑ 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 0 nits ❑ Jail or Exert pt Institution----Number of Units Employee Housing(2700) Use Employee Houslnsl/Labor Camp Appllcatlon Form 1, SITE MITIGATION(2900) T4 UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cieanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SgP Cleanup Site ElRWQCB Cleanup Site 13 Water Quality Remedlatlon Site RECREATIONAL HEALTH PROGRAM(3600) A Number of PooWSpas at Facility ��❑ Pool 1:1 Spa El Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm-------Maximum number of birds ❑ Kennel TATTOO.BODY PIERGING.PERMANENT COSMETIC PROGRAM(4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use(4120) ❑ Body Art Facility-Sterilization (41 1) ❑ Body Art Temp Event Co-ord (4130), ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) /J ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard El ackage Treatment Plant ❑ Chemical Toilets --Number of Units SOLID WASTE PROGRAM (4400) M ❑ Landflll ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(u or Units) ❑ Dumpsters>20 cu yd!(u of Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limped Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility P 2-10 ❑ 11 -60 ❑ >60 generators PU13LIO WATER SYSTEM PROGRAM (4600) Use PWS EHD 4G-02-Q0,7 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT FEE ❑ Surcharge FEF ❑ Other FEE INSPECTOR# PERMIT VALID to ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 40-02-034 MASTERFILE RECORD INFORMATION PINK Received Time May, 12, 2020 10 : 54AM No, 5983