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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Fa ility ❑New EH Program andNew Facilit Facilit ID 002(0)-0`� pro ram Record ID AZQy4ff7 Facility Address 10W - L S 520,01 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating CapacitySquare 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 ❑ 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 —may- ❑&Plant 11 Produce Stand EI Special Event---Dates of operation from to qp CFO L1Q A 11B 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) ❑ 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 Housfna/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) PAYMENT ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-SAM ❑ Body Art Facility-Sterilization(4121) ❑ Body Art Temp Event Coord(4130) ❑ Body Art-Temp Ev o ile Facilit (4131) LIQUID WASTE PROGRAM(4200) SEP 5 2�2�' ❑ Pumper Vehicle Registration# License# Capacity Rhicle# IV ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number otpRiWAQUIN — SOLID 1NASTE PROGRAM(4400) H NVI NT— ❑ Landfill [I Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility Ll Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd)#or units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing 0 Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 1:12- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form ,�7^,l� (r� "r \' CONTACT PERSON I/t1 EMERGEN Y NOrrTLF�ICATION FOR THDiisFACILITY AND/OR PROS Night PhW Wl' �lY J SM- PROGRAM PROGRAM ELEMENT FEE 1�J'�• ❑ Surchar a EE ❑ Other FEE INS PE TOR# �f yy,, PERMIT VALID / 2D t0 /aA I ❑ Food Handier ❑ �G('#��) z3 DiAMOU T Pao Date L, VOICE# 3 Iv77 ❑ Cash REVIEWED BY ACCOUNTING OFFICE ate � V2 46-02-034 MASTERFILE RECORDINFORMATION PINK imna