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SAN JOAQUIN COUNTY EIWONMENTAL HEALTH DEPART T MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID Program Record IID -<4c&3N77 Facility Address (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 ❑ Retail 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 B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP 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 S forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotei/`Viotei------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 ❑ NPLISEP 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 ❑ Kenner TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) itody 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# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill 13 Transfer Station ❑ Ag/Cannery Waste Site E] Sludq� T El Waste Tire Facility ❑ Compost Facility ElProcess/Recycle Facility ❑ CIA fir El Refuse Vehicles (#of Units) ElDumpsters>20 cu yd (#of units) ❑.Far At1EVWE4 Site MEDICAL WASTE PROGRAM(4500) ❑ IO Primary Care 11 Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator LJ Li teed H�uufer ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 1:12- 10 ❑ 11 -SAN JDAC"NMW PUBLIC WATER SYSTEM PROGRAM 4600 Use PWS EHD 46-02-003 Blue Application Form ENVIROMENTAL ( ) 1� HEALTH DEPARTMENT EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON aCICO C , :, Day Ph(QD)504-yLJ_4 I Night Ph PROGRAM ELEMENT kMFEE ❑ Surcharge Fti E El Other FEE INSPECTOR# -��,.J PERMIT VALID 10 LO t0 l ❑ Food Handler ❑ Check# AMOUNT PAID 5:5101a; Date 1()U'0WP INVOICE# '-Z'saaC99 ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date V/1-06 MASTERFILE REcORfD INFORMATION PINK 1/23/13