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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT R CE VED MASTERFILE RECORD INFORMATION FORM NO� p ❑New EH Pro ram at EE istin Facility ❑New EH Pro ram and New Fac]fly 8 20Z0 SAN jOA Facilit ID �o PPro ram/'Record ID D HEENV RQ01 CONNT, Facility Address 2-49-( I 664-c LI a ACTH DEPARTMENT (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 ❑ Retail Market quare footage ❑w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle—Make Vehicle Type Calor 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 lJI,A❑ B DAIRY PROGRAM(2000) ❑ Grade A Dalry ❑ 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) ❑ HoteUMOteI—Number of Units ❑Jail or Exempt Institution—Jumberof 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 ❑ NPLISEP 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 PcolslSpas at Facility _ ❑Pool ❑Spa ❑Out of Service PoolfSpa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Form--Maximumnumber of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body An Facility-Single Use(4120) ❑ Body Art Facility-Sterilization(4121) ❑Body Art Temp Event Covrd(4130) ❑ Body Art-Temp Event Mobile Facility(4131) UOUID WASTE PROGRAM(4200) ❑ Pumper VehicleRegisiration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑Chemical Toilets—Number of Units SOLID 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(9 of Units) ❑ Dumpsters>20 cu yd P d Units)_ ❑ FarmlRanch 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 ❑2-10 011-60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANWOR PROGRAM _ CONTACTPERSON Day Ph 7t14-4i10"25jNight Ph 2csr-A)O'Z5� PROGRAM ELEMENT— FEE .S b� ❑Sureha FEE ❑Other FEE INSPECTOR#A. )l ( � PERMIT VALID 0 2D to ❑ Food Handler ❑check# tAL r AMOUNT PAID •OU Date INVOICE#-31162-z> n ti rye Ae•nnueno Arra i+mnv:limn, al. bH V -20