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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ew EH Program <br /> at Existin Facility ❑New EH Program and New Facili ✓�/� O <br /> FacilityID 26,05 Pro ram Record ID s AI J, QUI ' �?Q <br /> Facility Address 5 30 S C1k�Pt pikAI <br /> e Q lodt C - g �4� EpgFro°ANry <br /> (Please check the appropriate description and specify ze number of units and pertinent Information.) RT.y <br /> FOOD PROD (1600) 9 <br /> Restaurant Seating Capacity Square Footage � )y J Food Handlers Course required: YE3)0� No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market—Square footage ❑w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant❑ Produce Stand <br /> ❑ Special Evert—Dates of operation from to ❑ CFO ❑ A❑ B <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dalry ❑ Grade B Dalry ❑ Milk Dispenser-Number of Containers in Mufti-Head Unit <br /> CUPA <br /> ❑ Hazardous Materials Business Plan(1900) Number of chemicals: <br /> ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator(2200) >-Tons Generated Per Year <br /> ❑ Tiered Permitting Facility—> ❑CA(2232) ❑ CE(2233,2234,2235,2137) ❑ PBR(2231) ❑ PBR HHW(2236) <br /> ❑ Aboveground Storage Tank Facility(AST)(2800) Number of ASTs <br /> ❑ Underground Storage Tank Program(UST)(2300)Use UST A and B forms <br /> ❑Other CUPA Program <br /> ROUSING PROGRAM(2400) <br /> ❑ Hotel/Motel—Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700) Use Employoo Hous/ng/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service PooUSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number of birds ❑ Kennel <br /> TATTOO.BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art FacllttySingle Use(4120) <br /> ❑ Body Art Facility-Sterilization(4121) ❑ Body Art Temp Event Coord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper VehicleRegistration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets dumber of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Slte ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles to ofunksl ❑ Dumpsters>20 cu yd aofunns> ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 ❑ 11 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46.02-003 Blue Application Form <br /> EmeRwNcy NoTiFICATION FOR THIS FACILITYAND/OR PROGRAM <br /> CONTACT PERSON Day Ph y lL Night Ph <br /> E ELEMENT FE S .d ❑ 3uroha FE ❑ Other FEE <br /> # PERMIT VALID Z t0 2 13 Food Handler <br /> PAID d• Date 2 INVOICE#REVIEwEo eY AcooulmNo OFFICE Date -71-2 FI,7Q <br /> 45-02-031 /����� _� MASTERFlLE RECORD INFORMATION PINK <br />