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pPq Y <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT °TFC L/ 1 <br /> MASTERFILE RECORD INFORMATION FORM J A' FD <br /> ❑New EH P Ia al Existin Facil' ON"EH P rem and Now FacilityJAIv <br /> V , C <br /> Facilit ID P ram Record ID S/,/pq ✓ �02� <br /> FacitityAddress E �5331F hEq�TIRpNINp <br /> (Please check the appropriate description an specify size.number of units and Pertinent information.) y pEp NO <br /> NTY <br /> FOOD PROGRAM(1600) gRrMFNr <br /> D Restaurant Seabng Capacity_ Square Footage Food Handlers Course required: YESA ND O <br /> O Commissary O Dry storage only O with Food Preparation OVending Machines Number of Units <br /> O Retail Market-Square footage O w/Meat Market only O Multiple Departments O Prepackaged Goods Only <br /> D Mobile Food Vehicle-Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> O Mobile Food Prep Unit-Make Venda Type Color <br /> Registration# License# Stickerh! <br /> O Temporary Food Facility-Dales of operation from to O Ice Plant O Produce Stand <br /> D Special Event—Dates of operation from to I CFO OA 1313 <br /> DAIRY PROGRAM(2000) <br /> O Grade A Dairy D Grade B Dairy D Milk Dispenser-Number of Containers in Muhl-Head Unit_ <br /> CUPA <br /> O Hazardous Materials Business Plan(1900) Number of chemicals: <br /> D CalARP Program O Program 1 Facility O Program 2 Facility D Program 3 Facility <br /> O Hazardous Waste Generator(2200)-->-Tons Generated Per Year <br /> O Tiered Permitting Facility—> OCA(2232) D CE(2233,2234,2235,2237) O PBR(2231) O PBR HHW(2236) <br /> O Aboveground Storage Tank Facility(AST)(2800) Number of ASTs <br /> O Underground Storage Tank Program(UST)(2300)Use USTA and B forms <br /> O Other CUPA Program <br /> HOUSING PROGRAM(2400) <br /> O Hotel/Motel--Number of Units O Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employ"Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> D Environmental Assessment O UST-CAP Site D Local HW Cleanup Site O NPUSEP Cleanup She D UIC Site <br /> O Abandoned HW Site O non-NPL/SEP Cleanup Site O RWOCS Cleanup Site O Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility O Pool O spa O Out of Service Pool/Spa O Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑Poultry Farm—Maximum number of birds O Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> O Body Art Practitioner Reg(4110) O Mechanical DSPS Notification(4115) O Body Art FacflitySingle Use(4120) <br /> D Body Art Facility-Stec lization(4121) O Body AR Temp Event Cord(4130) O Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> D Pumper VehicleRegistmflon# License# Capacity Vehicle# <br /> O Pumper Yard O Package Treatment Plant O Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> O Landfill O Transfer Station ❑AgiCannery Waste Site O Sludge/Ash Site <br /> D Waste Tire Facility O Compost Facility ❑Process/Recycle Facility O CIA Landfill Site <br /> O Refuse Vehicles(#of units) O Dumpsters>20 cu yd(#d unit)_ O Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> O Primary Care D Acute Cara O Skilled Nursing O Large Generator O Small Generator O Limited Hauler <br /> O Transfer Station D Veterinary Clinic O Common Storage Facility D 2-10 1311-60 O>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY molog PROGRAM <br /> CONTACTPERSO-1 L , T Day PhS.x%j-,Yi7/"'d/dpi/I Night Ph l(�/-kJ��-d�J C <br /> PROGRAM ELEMENT FEE D O Burchera FE D Other FEE <br /> INSPECTOR# � PERMIT VA <br /> D to / ❑Food Handler <br /> O CheckAmouNTIMmalIF Zd566 Date INVOICE# <br /> ❑Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> M1s-02.p34 MASTERFIIE RECORD INFORMuNTION PINK <br /> 123113 <br />