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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION F M ❑ New EH Program at Existing Facilit New EH Program and New Facilit Facility ID Zl- Program Record ID �5 ,32 Facility Address S2(Q-<- (Please check the appropriate description and specify size, umber ci units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating CapacitySquare 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 ❑ M9ifile 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 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) ❑ PER(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 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-NPLISEP 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) ❑ PoultryFarm-------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 &INIZA SOLID WASTEPROGRAM(4400) j11Landfill ❑ Transfer Station ElAglCannery Waste Site 101Sludg 7 111:31Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility CIA Lan I !/cc//�� 11 Refuse Vehicles(#of Units) ElDumpsters>20 cu yd (#of units) ❑ Farm¢•i 1ph.Clea iuNte MEDICAL WASTE PROGRAM(4500) U2 20 ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small GeneratoE j> �d HaulSr ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112-10 ❑ 11 -mEAL $tpFs PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form // gqDEPf1 RT�gEfYT�y ^ MERGENCVNOTIFICATIONFORTDHIaSYFPA�CILITYANDIOU ROGRANightPk )� ITI /�S� l CONTACT PERSON lV. 0.0. /\ `n1 PROGRAM ELEMMENNT? FEE '00 ❑ Surcharge FEE ❑ Other FEE INSPECTOR# IOJ PERMIT VALID --2 D t0 2Dry 11 Food Handler Q ❑ Check# AMOUNT PAID 2-3-4 Date -L-0 INVOICE# /0 LM/Cash REVIEWED BY ACCOUNTING OFFICE 17 —j Date 48-02-034 MASTERFILE RE ORD k44FORMATION PINK 1/23/13