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SAN JOAQUIN COUNTY IRONMENTAL HEALTH DEPAF =NT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existinq Facility ❑New EH Program and New Facility p Facility ID r460Z2D` 0 Program Record ID Vk65_39-1S % N 1NINUMVida0 HCTt3H WILN31NOHIAN3 uNnoO NlnoVor kvs RIOZ 4 8'AON 3338 Facility Address n 1A98"K W 17 C Y)(17)A-(ll L�d �f/G/l.) Gl�i- 9 ��Ildd (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) ❑ RestaurantRestauran: Seating Capacity_ Square Footage Food Handlers Course required: YES ❑ No El ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market ----Square footaElw/Meat Market only Multiple Departments ElPrepackaged oods Only Ct�e Mobile Food Vehicle --Make U VX r` E7 e1 W3 Vehicle Type Op+ Color W h/ +e— Registration # License # BOAT Sticker # ❑ Mobile Food Prep Unit-- Make Veh'ide Type Color Registration # License # Sticker # ❑ Temporary Food Facility --Dates of operation from to ❑ Ice 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 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 ��/� El Permitting Facility -------> ❑ CA (2232) El (2233, 2234, 2235, 2237) El (2231• frj (2236) El Aboveground Storage Tank Facility (AST) (2800) Number of ASTs �(jC ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms NOV 0 4 M3 ❑ Other CUPA Program couffly HOUSING PROGRAM (2400)�At ❑ Hotel/Motel ------Number of Units ❑ Jail or Exempt Institution ----;!=6f Employee Housing (2700) Use Employee Housino/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 # ❑ Pumper Yard License # ❑ Package Treatment Plant Capacity Vehicle # ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station [IAg/Cannery Waste Site ElSludge/Ash Site 1:1Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles I# of units) ❑ Dumpsters > 20 cu yd (u 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 - 10 011-60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form r CONTACT PERSON X -� Lft Day Ph &q-L/LO -6.51') Night Ph N1 -C_ PROGRAM ELEMENT L/e37 Q FEE — ❑ Surcha ge FEE [3Other FEE INSPECTOR# PERMIT VALID Z( t0 13 ❑ Food Handler q ❑ Check # AMOUN PAID Date INVOICE # ash REVIEWED BY _ ACCOUNTING OFFICE Date �� ) 48-02-034 MASTERFILE RECORO INFORMATION PINK 1/23113