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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM '°'4 Y ❑New EH Proat Existin Faci i ew EH Pro rem end Naw Fae II C�'� Facill ID ROO Program Acord ID D 2? �Cj VFQ Facility Address ( V F goy ?0?,9?D FooDP OGRathe M(1600)appropriate deacripdonand spedtypIf andpertinentI fonnaOonTFgGTy'Oy�NC ��ry 13 Commissary 13 Dry storage only 13Restaurant Seating Capacity_ Square Footage Food Handlers Coursereaulred; YES dQ� with Food Preparation ❑Vending Machines Number ol Units �Retall Market—Square footage ❑w/Meat Market only E3Multiple Departments O Prepackaged Goods Only (b]�Moblle 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 ❑lee 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 Mut&Head Unit CUPA ❑ Hazardous Materials Business Pian(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—> OCA(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 Housina/Labor Cama ApolicaUon Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑UIC Site j ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑Water Quality Remediation Site j 11 RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility _ ❑Pool ❑ Spa ❑Out of Service Pool/Spa ❑ Nawrai Bathing Area YECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm--Maximum number of birds ❑ Kennel TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) ❑ Body AR Practitloner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body AR Facility-Single Use(4120) ❑ Body Art Facility-Sterilization(4121) ❑Body Art Temp Event Coord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper VehicleRegistra8on# License# Capacity Vehide# ❑ Pumper Yard ❑Package Treatment Plant ❑Chemical Toilets—Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑siudge/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑Procesa/Racycle Facility ❑CIA Landfill Site QRefuse Vehicles(rofunm) 0Dumpstera>20euydpofunh) _ ❑FamdRanchCleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station O Veterinary Clinic ❑ Common Storage Facility ❑2-10 ❑ 11.60 ❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 4602409 Blue Application Form X CONTACT PERSON N Day Ph 1 Nlght Ph PROGRAM ELEMENT 11020 F O ❑Surchsrga FE ❑Other FEE INSPECTOR# PERMITVALID ZD to �� 3( 2 O Food Handler ❑mod #dAMOUNT PAI09 /D7. OD Date 20 INVOICE# 13 Cash REviEwED BY AccouNnNO OFFICE Date lb 4M2-0al MASTERFILE RECORD INFORMATION PINK 1 ,13 //S 1307 f