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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT -r I MASTERFILE RECORD INFORMATION FORM ❑ New EH Pro ram at Existing Facility 11New EH Pro ram and New Faculty V �... Facility IDo _ Program Record ID T ` Facility Address 2Z`A S" Gl\c c4-e 2 w� s'�� ►� s2 0� s (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 11 Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units D.Rptail.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 0 Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA . ❑,Hazardous Materials B1.18111e5S Plan, (1;700) Number of chemicals:. ❑ CaIARP Program ❑ Program 1 Facility ❑ Program.2.Facility 13 Program 3 Facility Y ❑ 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(FIST) (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 Employes Housing& bor Camp-Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup.Stte ❑ NPLISEP Cleanup Site ❑ Ulc Site ❑ Abandoned HW Site ❑ non-NPLISEP Cfeanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RE,CRE-ATIQNAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry f=arm-------Maximum number of birds ❑ Kennel TATTOO,BODY PIERCING.PERMANENT COSMETIC PROGRAM(4100) . ❑ Body Ari Practitioner Reg (4110) ❑ Mechanical DSPS Notification(41.15) ❑ Body Alt FaclUty-Slrlgle.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) ,;;121-Pumper VehlcleRegistration#__. _ License# Capacity Vehicle# S Pumper Yard ❑ Package Treatment Plant Chemical Toilets----Number of Units , SOLID WASTE PROGRAM (4400) El Landfill ❑Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd(#or Unas) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Aerie Care ❑ Skilled Nursing ❑ Large Generator. ❑ Small Generator ❑ Limited Hauler ❑,Transfer Station ❑ Veterinary Clinic ❑ ..Common Storage Facility O 2-10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form EM_RrFNcv NOTIFICATION FOR THIs FA ILITY oR PROGRAM CONTACT PERSON `%E $L-V h�WtL�cHA�. Day Phl.Qlt13A1 ttU Night PhVICt-�Oti-`�(-T� PROGRAM ELEMsE�N�T d/2-44 l— FEE v El.Surcharge F ❑ Other FEE fINSPECTOR# V" i PERNIIT VALID to ` l �t 1:1Food Handler ❑ Check#_+ A.souNT PAID Date INVOICE# D ❑ Cash "REVIEV0=D BY ACCOUNTING OFFICE Date AD•02-034 7 f 2-4 MASTERFILE RECO D INFORMATION PINK