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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ew EH Program and New Facili Facility ID 2 Program Record ID RD$ 3 Facility Addressat-QoMt -yc,he it Cees i (A 9s3o-7 (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 ❑ Reil Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only obile Food Vehicle--Make AA PL Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Cn� OA Tyri if✓ 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 ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PER 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 Cama 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) Cl 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) vwRE�T 1:1Pumper Vehicle Registration# License# Capacity PAI IV C�' El Pumper Yard ❑ Package Treatment Plant 13 Chemical Toilets----Numb tV c'' SOLID WASTE PROGRAM (4400) Z� 1:1 Landfill 11 Transfer Station 13 ,y(1`I (� 29Ag/Cannery Waste Site LLA�B A Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ ptllfAlqN'9 1:1 Refuse Vehicles(#or units) ❑ Dumpsters> 20 cu yd (#or Units) S@IiAOFtt��nup Site MEDICAL WASTE PROGRAM (4500) HFALTH DEP ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form 11 EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON CvQ1 ad0f 11 0 'Dayl`h,SZ9'= — Z02?—Night Ph PROGRAM ELEMENT FEE '00 ❑ Surcha ge FE 1:1 Other FEE INSPECTOR# PERMIT VALID UlZ to 1 3I I ❑ Food Handler V❑ heck# AMOUNT PAID � Z17�- — Date � 2- lid INVOICE# 3 ,, y3 Cash REVIEWED BY ACCOUNTING OFFICE Date LLl 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13