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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM YNew EH Program at Existing Facility ❑New EH Program and New Facili Facili ID Program Record ID Facility Address W- 7aS4tjjij1fA Tau MVA+A�" (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square 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 / ❑ Ice#lant❑ Produce Stand ❑ Special Event--Dates of operation from to Vf CFO O'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 USTA 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 HousinalLabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP 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 Coord(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 R of units) ❑ Dumpsters>20 cu yd(#of units) ❑ FarmimlaQygSite MEDICAL WASTE PROGRAM(4500) REc CC11�tl�� ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing El Large Generator 11 Small Generator ElLlm r ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 ❑ 11 -60 SFIP$Yenerators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form SAN [ CC 2�ZQ EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM JOAQUIN COUW7r. CONTACT PERSON Preetha Joycy Bellary Joseph II__ Day Ph 6696009414 Night Ph N ME PROGRAM ELEMENT FEE ..0 1J ❑ Surcharge FEE ❑ Other FEE ENT IINNS/PECTOR# PERMITVALID r�-�-r� t0 [3 Food Handler Dl Check# AMOUNT PAID ��J(/•-- Date _ INVOICE# 13 Cash REVIEWED BY 1_nj/Lr(2 S. ACCOUNTING OFFICE igg 2ZZC Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13