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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION F RM ❑ New EH Pro ram at Existing Facility yew EH Program and New Facility Facility ID Program Record ID Facility Address zi'16f g537Cv (Please check the appropriate description and specify size, numbe f units and pertinent information.) FOOD PROGRAM(1600) P� �+�,� 11ired:Restaurant: Seating Capacity Square Footage Food Handlers Course re a "rte ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Unit ❑ Retail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepacl �oods tfly 1:1 Mobile Food Vehicle--Make Vehicle Type Color 8 9mn Registration# License# Sticker# ✓O Mobile Food Prep Unit-Makq Vehicle Type y (2 l0 Co16lit ROZ�OUAn,. Registration# License# q1Sticker# E T ❑ Temporary Food Facility-Dates of operation from t0 ❑ Ice Plant ❑ tand ❑ 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) ❑ PER(2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST)(2300) Use UST A and 8 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 ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles I#of units) ❑ Dumpsters> 20 cu yd (#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 RGEN TIFICATION FOR THIS FACILITY AND/OR PROGRAM / CONTACT PERSON Day Ph-/-,'Yo-7 -✓S i fliPh -7 1 -63 2I PROGRAM ELEMENT L FEE 2313 Surchar e F E 11 Other FEE INSPECTOR# PERMIT VALID Q IgZD t0 13 ❑ Food Handier ❑ Check# Nf& AMO T PAID •0 Date VIM INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date `r 22 48-02-034 �' �� MASTERFILE R COR INFORMATION PINK 1/23/13