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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION F RM ❑ New EH Program at Existing Facility New EH Program and New Facili Facilit ID Program Record ID QD ID Facility Address a va g53ql (Please check the appropriate description and specify size, number of units and pertinent information.) Ab Y FOOD PROGRAM(1600) RR '7 � pr 11 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs�Q�' F T ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Unity Q ❑fiWtail Market—Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Preps ad�x Lid"Mobile Food Vehicle—Make Vehicle Type Color NNU Q Registration# License# Sticker# N / /N ❑ Mobile Food Prep Unit--Make Vehicle Type Color N i 7), Registration# License# Sticker# 'IR71;r ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Produce Moll ❑ 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: ❑ CalARP 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 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-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa Cl 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 ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles 1#of Units) ❑ Dumpsters>20 cu yd I#of Units) ❑ Farm/Ranch 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 ❑ 2- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02.003 Blue Application Form HIS CONTACT PERSON N lJl l I t� EMERGENCY NOTIFICATION FOR FPAhCILITY AND/OR P OGRAIL Night Ph PROGRAM ELE EENTT ) FE ❑ Surchar 7e F E ❑ Other FEE INSPECTOR# JO`/ PERMIT VALID g t0 Z J y� ❑ Food Handler ❑ Check# AMOUNT PAID '� Date 2U INVOICE# � gb Cash REVIEWED BY L ACCOUNTING OFFICE Date (1 ZD 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13