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SAM JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at.Existing Facility 2New EH Program and New Fac it Facility ID Program Record ID 4,,135-0 Facility Address -VU(o l r(C7J� 2 �M C'Sa� (Please check the appropriate description and specify size.number of urnts and pertirpYlt lNmrrualeon) FOOD PROGRAM(1600) ❑ Restaurant: Seating CapacitySquare Footage Food Handlers Course required: YEs❑ No ❑ ❑ commissary ❑Dry storage only D with Food Preparation OVending Machines Number of Units ❑Retad liarket Square footage ❑udmeat Market only ❑ Muilqie Departments 0 Prepackaged Goods Only ❑ Mobile Food Vehicle-Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Faod Prep Unit-Make Vehicle Type Color Registration# License# Sti er# ❑ Temporary Food Facility-Dates of operation from to Ice�Ptard 0 Produce Stand ❑ Special Event—Dates of operation from to CFO VA 0 B DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Disperser-Number of Containers in Mulb Head Unit COPA ❑ 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)(28M) Number of ASTs ❑ Underground Storage Tank Program(UST)(2300)Use UST A and B forms ❑Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motal—Number of Units ❑.fail or Exempt Institution—Number of Units Employee Housing(2700)Use Employee HopshWlLabor Camp Application Form SITE MITIGATI MI(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment IZ UST-CAP Site ❑ Local HW Cleanup She ❑ NPLISEP Cteannup Site ❑ UIC Site ❑ Abandoned HW Site ❑non-NPL/SEP Cleanup Site ❑ RWQC8 Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Poots/Spas at Facility ❑Pool ❑ Spa ❑Out of Service PooUSpa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farmer"atimum number of birds ❑ Kennel TATTOO,BODY PIERCING.PERMANENT COSMETIC PROGRAM(4100) ❑ Body Art Practitioner Reg(4110) ❑Mechanical DSPS Notification(4115) ❑ Body AR Facility-Single Use(4120) ❑ Body Art Facility erilaation(4121) ❑Body Art Temp Event Coord(4130) ❑Body ArtTemp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plard ❑ Chemical Toilets—Number of UM PAY] r SOLID WASTE PROGRAM(4400) RECEIVED ❑ Landfill ❑Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste rue Facility ❑Compost Facility ❑ProcesslRecycle Facility ❑ CIA QViiiI 4 020 ❑ Refuse Vehicles(1#of unit) ❑Dumpsters>20 cu yd(r#of units) ❑Farm/Ranch Q U C�ft"ite MEDICAL WASTE PROGRAM 4500 SAN MAROON ( ) ENVIRONMENTAL ❑ Primary Care ❑ Acute Care ❑ Skip[Nursfru3 ❑Large General" ❑ SmaB Generakm�1fkfw8HTMW ❑ Transfer Station ❑lfeterhrary Clink ❑ Common Storage Facility ❑2-10 011-60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form vNo roRTmFACILITY um/oRPROGRAM CONTACT PERSON A -Day Ph O Night Ph PROGRAM ELEMENT FEE ❑ Surcha41FE ❑ Other FEE INSP\E/CTO�R,�# PERMITVALID 20 to ❑ Food Handler`' /❑ g1�ld # 2-AMOUNT PAID ( Date i Iv VOICE# C2i ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 1123113