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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RF�FMFHr MASTERFILE RECORD INFORMATION FORM NQ'/ SFO ❑ New EH Program at Existing Fact lit ❑New EH Pro ram and New Facilit 1 ?010 Facilit ID Pro ram Record ID NFq��VbbRO�/NSC ?0 FaciliAddrgss�2 - DGv`i \c -s- tyr�} ect C� • �L �Ty (Please check the appropriate description and specify size,number of units and pertinent information.) Hr FOOD PROGRAM(1600) VIKResta_urant: Sealing 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 0 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) ❑ PER HHW(2236) ❑ Aboveground Storage Tank Facility(AST)(2800) Number ofASTs ❑ Underground Storage Tank Program(UST)(2300) Use UST A and B forms ❑Other CUPA Program HOUSING PROGRAM(2400) ❑ HotellMotel------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 i ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) I 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 VehicleRegistration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles I#of units) ❑ Dumpsters>20 cu yd I#of units) ❑ 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 1:12-10 ❑ 11 -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 _ ONTACT PERSON ay Ph - -(o ight Ph 2ZCL 7'(P G O v PROGRAM ELEMENT FEE _O ❑ Surchar FEE ❑ Other FEE INSPECTOR# PERMIT VALID �� ZD to �( 3b ❑ Food Handler ❑ Check# AMOUNT PAI lip, nin Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date /,2: 48-02-034 �� (/^/� IE-1 R OR INFORMATION PINK 1123/13