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�1 ...'SAN..JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT t _MAS_TERFILE RECORD INFORMATION FORM -� ❑ New EH Pro ran at Existing Facility WNew EH Pro Rram and New Facility FacilityID C11i_ Z- Program Record ID -- --- Facility Address ZL.H' ' C_ t1r+��wY S-roc� ►J C,ac�SZoco (Please check the appropriate description and specify size,number of units and pertinent information,) FOOD PROGRAM(1600) ❑ Restaurant Seating C ipacity______ Square Footage Food Handlers Course required:. Yes ❑ No O ❑ commissary,Q Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market----Square fOGtage ❑ w/Meat<Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle-•fJlalce - Vehicle Type Color Registration t# License# Sticker 4 ❑ Mobile Food Prep Unit--Make ''Vehlcle 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 COPA ❑ Hazardous Materials Business Pian 0900) Number of chemicals: Cl 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 StoriUe Tank Facility (AST) (2300) Number of ASTs ❑ Underground Storage Tank Program (UST)(2300) Use UST A and S forms ❑Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing(2700) Use E.rrl Igyer—1 loysin /q 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-NIPLiSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site,, RECREAT ONAL HEALTH PROGRAM(3600) Number of,PoolslSpas at Faciiity _ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4 0001 ❑ Poultry Farm-----•-h4a.41111R11 liUrnber of aids ❑ Kennel TATTOO,BODY PIERCING,PF..RMIANENT c"OSMETIC PROGRAM(4100) . ❑ Body Art.Practitioner f teg (41101) 12, 114echanical 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(42010) w F EPumper VehicleRegistration# License# � b0lp5lcapacity/5?�0 �O Vehicle# l Pumper Yard ❑ Package Treatment Plant Chemical Toilets----Number of Units SOLID WASTE PROGRAM(4400) El Landfill LEITransfer Station ElAgfCannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles p of Units) ❑ Dumpsters>20 cu yd(a or Units) ❑ Farm/Ranch Cleanup Site " MEDICAL WASTg PROGRAM (4500) ❑ Primary Care ❑ Acute Care '1 Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler © Transfer Station ❑ Voterhiary Clinlic ❑ Common Storage Facility ❑ 2- 10 011 -60 ❑ >60 generators PUBLIC WATER SYSTEM PI:OGRAM (460;:) t.:So PWS EHD 46-02-003 Blue AP211catfon Fgrm EfA;iietiEI1CY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON !/off M4 tie fit.A Day Ph LPA 3117-L11(e Night Ph IV a� S/yam PROGRAM ELEMENT -� EE Ill •D ❑ 5urchar e F e 13 Other FEE INSf ECTOR# PER` %!N, I IG 2 to I "3"� ❑ Food Handler ❑.Check#" C..tc 42& A rr"U IIT P-"!!) Date f INVOICE# ❑ Cash REV t_b'.IcD CY ACCOUNTING OFFICE Date 4,0.02-034 MASTERFILE RECORD INFORMATION PINK z C� 03772�/a