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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility El New EH Program and New Facility Facility ID d 15 Program Record ID Facility Address )211 S. 14" M00jeSN CA 8535 I (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 AlMobile 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❑ 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) ❑ PER(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 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 ❑ Sludtan AA..Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIAN7- ❑ Refuse Vehicleso of Units) ❑ Dumpsters>20 cu yd I#of Units) ❑ Farm Site MEDICAL WASTE PROGRAM(4500) -''1� {{ ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing 11 Large Generator ❑ Small Genr;g 3� L?1At@�uler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility El - 10 El11H6/Vt,", generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form FALTHDFPMRTT�01 7 , / I, EMERGE NCYNOTIFICATIONFOR THIS FACILITY AND/OR PROGRAM ��v� M CONTACT PERSON ` �L V I Day Ph 2 Z Night Ph -01.3�2��/2 PROGRAM ELEMENT FEEAE 2 �' 11Surchar e F El Other FEE INSPECTOR# PERMIT VALID �1 to 1 3I 2020 ❑ Food Handler Q Check# 1 D31 AMOu T PAID Date INVOICE# 11 Cash REVIEWED BY ACCOUNTING OFFICE _ Date 7 48-02-034 V MASTERFILE RtCORb INFORMATION PINK 1/23/13