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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> 0 New EH Program at ExistingFacilityew EH Pr ram and New Facility <br /> Facilit ID O 241 Pro ram Record ID <br /> Facility Address__�� g--- __ _ _.f__I Y.___LLj-_MQ9__Lj`}___cT536 <br /> (Please check the appropriate description and specify size number of units and pertinent information.) ' <br /> FOOD PROGRAM(1600) <br /> 0 Restaurant Seating Capacity______ Square Footage___________ Food Handlers Course required: YES 0 No 0 <br /> 0 Commissary O Dry storage only O with Food Preparation OVending Machines Number of Units --------- <br /> • Retail Market----Square footage____________ 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br /> 0 Mobile Food Vehicle--Make------------------------ Vehicle Type-------------------- Color----------------- <br /> Registration# <br /> ___Registration#_______________________ License#------------------- Sticker#_________________ <br /> 0 Mobile Food Prep Unit–Make____________________ Vehicle Type_____________________ Color________________ <br /> Registration#_________ ____________ License#------------------ Sticker# <br /> 0 Temporary Food Facility--Dates of operation from___ ____ _____ to ____ ________ 0 Ice Plant 0 Produce Stand <br /> 0 Special Event—Dates of operation from------------------ to _____ __ PICFO�'RPA 0 B <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit ____ <br /> CUPA <br /> 0 Hazardous Materials Business Plan(1900) Number of chemicals: --------- <br /> • CaIARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br /> O Hazardous Waste Generator(2200)---------->-Tons Generated Per Year____________ <br /> 0 Tiered Permitting Facility-------> 0 CA(2232) 0 CE(2233,2234,2235,2237) 0 PBR(2231) O PBR HHW(2236) <br /> 0 Aboveground Storage Tank Facility(AST)(2800) Number of ASTs--------- <br /> 0 Underground Storage Tank Program(UST)(2300)Use USTA and B forms <br /> 0 Other COPA Program________________________________________________________ <br /> HOUSING PROGRAM(2400) <br /> 0 HoteUMotel------Number of Units __________ ❑Jail or Exempt Institution—Number of Units _________ <br /> Employee Housing(2700)Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 0 Environmental Assessment O UST-CAP She 0 Local HW Cleanup She 0 NPL/SEP Cleanup Site 0 UIC She <br /> 0 Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility _____ 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> 0 Poultry Farm----Maximum number of birds__________________ 0 Kennel <br /> TATTOO.BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> 0 Body Art Practitioner Reg(4110) 0 Mechanical DSPS Notification(4115) 0 Body Art Facility-Single Use(4120) <br /> 0 Body Art Facility-Sterilization(4121) 0 Body Art Temp Event Co-ord(4130) 0 Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> O Pumper Vehicle Registration#--------------- License#------------- Capacity ------------ Vehicle#_________ <br /> 0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets----Number of Units _____________ <br /> SOLID WASTE PROGRAM(4400) <br /> 0 Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site�A�� <br /> 1:1 Waste Tire Facility 0 0 0 Compost Facility Process/Recycle Facility CIA Landfill S' ��''ii �jV'F <br /> O Refuse Vehicles Oof units)________ O Dumpsters>20 cu yd(#m unft) ______ 0 Farm/Ranch <br /> MEDICAL WASTE PROGRAM(4500) ��® <br /> 0 Primary Care 0 Acute Care ❑Skilled Nursing 0 Large Generator 0 Small Generator 0 Limitooul a /y <br /> 0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2-10 011 -60 0 >60 gonr�a rs7 ?02U <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form SJ JOq <br /> aG LY TIFIL ONFORTHIEF C L YA GRAM N�OUl ENTAD Ty <br /> CONTACT PERSON_ U _ Day P jp (1 1'I'�___bfL Night P f --- <br /> _ _________ <br /> T <br /> PROGRAM ELECM,lE�NT �_ FEE ___ r _ 0 Surch eFE _______ ❑ Other FEE _____________ <br /> INSP CTOR# _!�8 ___ PERMIT VALID _�� z� t0 � 3� ZJ_ O Food Handler __ <br /> _ 7 / ? <br /> _ IQ 2� INVOICE# ? Io' 3� <br /> Check# _��-� AMOUNT PAID �� Date __ � yl _ -------- <br /> 13 Cash REVIEWED BY ACCOUNTING OFFICE Date �� Z <br /> 48-02-034 MASTERFILE R CORD INFORNATION PINK <br /> 123/13 <br />