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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RF YM, <br /> MASTERFILE RECORD INFORMATION FORM V�D <br /> ❑ New EH Program at Existing Facility E3 ew EH Program and New Facilt MAR 0 <br /> Facility ID CO Program Record ID SqN J ??021 <br /> O <br /> Facility Address 2 r3 S W ICiI�C �'fi 7i-tt CV NzaLrN�NMFWk <br /> NT', <br /> (Please check the appropriate description and specify size number of unl4s and oertlnatlon.) ART <br /> Ro9BM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required: YES❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market—Square footage ❑w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle-Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit-Make Vehide Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility-Dates of operation from to 1 ❑ Ice Pla�❑ Produce Stand <br /> ❑ Special Event—Dates of operation from to ,6'CF0 ❑A W B <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit _ <br /> CUPA <br /> ❑ Hazardous Materials Business Plan(1900) Number of chemicals: <br /> ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator(2200)-->-Tons Generated Per Year <br /> ❑ Tiered Permitting Facility---> ❑CA(2232) ❑ CE(2233,2234,2235,2237) ❑ PBR(2231) ❑ PBR HHW(2236) <br /> ❑ Aboveground Storage Tank Facility(AST)(2800) Number of ASTs <br /> ❑ Underground Storage Tank Program(UST)(2300)Use USTA and B forms <br /> ❑Other CUPA Program <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Mote1—Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employee Houslna/Labor Camp Aeglicadon Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility _ ❑Pool ❑ Spa ❑Out of Service PooUSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—f.aAmum number of birds ❑ Kenna] <br /> TATTOO,BODY PIERCING.PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art Facility-Single Use(4120) <br /> ❑ Body Art Facifity-Stertiization(4121) ❑Body Art Temp Event Coord(4130) ❑ Body Art-Tamp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper VehicleRegWration# License# Capacity Vehide# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles tr a unb) ❑ Dumpsters>20 cu yd(ir or unb) ❑ Farn/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 ❑ 11 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-W3 Blue Apolleadon Form <br /> EuERGEN oTwx:ATPomFORTHIsFACILITYAND/ PROGRAM <br /> CONTACT PERSON 41 - Day Ph g Ph <br /> PROGRAM F-LEMENT­ _ FEE ❑ Surcha FE 13 Other FEE <br /> # <br /> INSPECTORPERMITVAUD 2 to 73 ZZ ❑ Food Handier <br /> ❑ check# AMouNTPAID b. UO Date 3 2 INVOICE# <br /> 7772 <br /> CSW 12/46 X746 <br />