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1: SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID 3l Program Record ID P K q� °{ 3 2 Facility Address LD 20 S S(/1GK V1IC*%1'U ':4 - Wj-, CA (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 ❑ Detail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ,GI Mobile Food Vehicle--Make Vehicle Typ 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: ❑ CalARP 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) ❑ 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 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 ❑ Abandoned HW Site ❑ non-NPL/SEP 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 Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ElPumper Yard ElPackage Treatment Plant ElChemical Toilets----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Slud ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA ❑ Refuse Vehicles (#of Units) ❑ Dumpsters>20 cu yd (#of Units) ❑ Far Ranch Site MEDICAL WASTE PROGRAM (4500) DEC ' ❑ Primary Care El Acute Care El Skilled Nursing 11 Large Generator ❑ Small Gener$q LlmltSeder ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 - H fN �@�, at rs PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EALTfj pEp��r4L ry EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM MENT CONTACTPERSON L Day Ph gt)!�� lS SOGlight Ph - 50 6 PROGRAM ELEMENT toy FEE J �7 ❑ Surchar a FEE ElOther FEE INSPECTOR# 3?JIQ� PERMITVALID 2-U to ❑ Food Handler ❑ Check# _ AMOUNT PAID Date 12- 19 2D INVOICE# j.hj 20 ® CBs2 3 11 REVIEWED BY ACCOUNTING OFFICE Date 2 48-02-034 MASTERFILE RE ORD IfiFORMATION PINK 1/23/13