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R , SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT JUhECFn,OT MASTERFILE RECORD INFORMATION FORM 1y �,D4 1o�s ❑New EH Program at Existing Facility ❑New EH Program and New Facill N � R Facility ID FQD02-30b Program Record ID �F Y' Facility Address \ DO 'Z\G+�ck�R�s i,Jfl• S6tU�hµ�r►�° �'� 01 (Please check the appropriate description and specifyLee,number of units and pertinent information.) FOOD PROGRAM(1600) 1 ❑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 k t�k Color Registration License# $ticker# 5 ❑ Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# ❑Temporary Food Facility—Dales of operation from to ❑ Ica Plant❑ Produce Stand ❑ Special Event—Dates of operation from to ❑ CFO ❑A❑ B DAIRY PROGRAM(2000) ❑ Grade A Dalry ❑ Grade B Dalry ❑ Milk Dispenser-Number of Containers in Multi-Head Unit_ CUPA ❑ Hazardous Materials Business Plan(1900) Number of chemicals: 13CaIARP Program 1 ❑ 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) ❑ 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/Matel--Number of Units ❑Jail or Exempt Institution--Number of Units Employee Housing(2700)Use Employee Houslnc&aborCamp 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 E}non-NPLJSEP Cleanup Site ❑ RWQCB Cleanup Site ❑Water Quality Remedlation 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 AR Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art FacilltySingle Use(4120) ❑ Body AR 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 SOLID WASTE PROGRAM(4400) ❑ Landfill 13 Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#aura.) ❑ Dumpsters>20 cu yd(#orumm) ❑ 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 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form G NC N TFICA ON FOR THIS FACILITY AND/Olt PROGRAM CONTACT PERSON 10 6-A Su W l�lo Day Ph o jt • 3 b•c yt Ph PROGRAM ELEMENT I FEE 3� 13 Surcharge FE E3 other FEE INSPECTOR# Ol � PER htITV !T- [3AL to 3, Food Handler ❑ Cheek# /YT`�)S'bSam AMOi�U:PAID .Z�•DD pate -� INVOICE# 13 Cash REVIEWED BY i6JLACCOUNTING OFFICE Date &0: 46-02.034 MASTERFILE REC9RD INFORMATION PINK