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SAN JOAQUIN COUNTY E IRONMENTAL HEALTH DEPAR =NT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID w2-4A641 _ Program Record IDps '7�� Facility Address —M �-, lokv (Please check the appropriate description and specif size, Lmb,r of units and pertinent information.) FOOD PROGRAM (1600) ❑l Restaurant: Seating Capacity_ Square Footage Food Handlers Course required: YES ❑ No ❑ LTJ 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# -✓�-O� ❑ 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: ❑ 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 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) RR /1 F•r� El Landfill 1:1 Transfer Station ElAg/Cannery Waste Site ElSludge/Ash SifrCA � 1:1Waste Tire Facility ❑ Compost Facility ElProcess/Recycle Facility ❑ CIA Landfill 99 t�Q El Refuse Vehicles (#of units) ElDumpsters> 20 cu yd (#of Units) ❑ Farm/R cl 4:14 MEDICAL WASTE PROGRAM (4500) e, d0AQ4W ! �o ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ly (/N ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑-'11 -60 ❑ >60 g ygj�C PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Fomt NT EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM C*ACT PERSONt may,r�� Day Ph 6'D ight Ph �J(b=- PROGRAM ELEMENT I !0./ J FEE 2 ❑ Surcharge FEE ❑ Other FEE INSPECTOR# �_ PERMIT VALID 1$ tO ❑ Food Handler ElCheck# AMOUNT PAIDDate g 14I 1 INVOICE# Cash REVIEWED BY ACCOUNTING OFFICE Date q �� 48-02-034 MASTERFILE RECOVE)INFORMATION PINI( 1/23/13