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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT R CF FLN� r MASTERFILE RECORD INFORMATION FORM NoV 06 /�cO ❑ New EH Program at Existing Faclli ew EH Program and,New Facil' qN 1 S F^✓OgQ �20 Facili ID a021o2S� Pro ram Record ID 3 hFq�HDEp FN��NTy Facility Address �°i $ A\ l� D-en� M(gtrnj� $�CAcISsti) 4R)..4 (Please check the appropriate description and specify size,number of units and pertinent information.) Nl FOOD PROGRAM(1600) J ❑ Restaurant: Seating Capacity Square 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 ❑ Mobile 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-----> OCA(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 Housinn/Labor Camp Application Forth SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP 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) ❑ 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 Coord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper VehicleRegistration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units S ID WASTE PROGRAM(4400) Landfill ❑Transfer Station ❑ AglCannery Waste Site ❑ Sludge/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd t#of unlls) ❑ 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 1311 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph 1oS0—S'60-lobblliight Ph PROGRAM ELEMENT \lO FEE l S 1:1Surchattt1aaa7eee EE 11 Other FEE (o INSPECTOR# �.�(��^AfeS PERMITVAUD ZU to 1/3 ❑ Food Handler ❑Check# :5A-- AMOtMTPAiD �EIS,<(06 Date INVOICE# Am ❑Cash REVIEWEOe AccouNTmG OFFICE Date 48-02-034 MASTERFILE RErORD4NFORMATION PINK 1123/13 aS , // 6 S-� 6,5,/