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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ New EH Program at ExistingFacilityew EH Program and New Facility <br /> Facility ID Program Record ID <br /> Facility Address 1010 lnry \,I Ly —N-mL,j LA 9 S;y-W <br /> (Please check the appropriate description and specify sJ number of units and pertinent Information.) <br /> FOOD PROGRAM(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 /> 11 Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to ❑ Ic Plant El Produce Stand <br /> 11 Special Event—Dates of operation from to El CFO LIr<A ❑ B <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUPA <br /> O 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 UST A and B forms <br /> ❑ Other CUPA Program <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteVMotel—Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employee Nousini—V5bor Camp Application Form <br /> SrrE MMGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br /> ❑Abandoned HW Site ❑ non-NPL/SEP 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 Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑Poultry Farm—Maximum number of birds ❑ Kennel <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 Facility-Sterilization(4121) ❑Body Art Temp Event Coord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑Pumper Vehicle Registration# License# Capacity Vehicle# <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(#of Units) ❑ Dumpsters>20 cu yd (#of units) ❑ Farm/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 END 46-02-003 Blue App//cation Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM <br /> CONTACT PERSON i Day Ph S 1(� 41 x IS Q(L Night Ph <br /> PROGRAM ELEMENT��� FEE ( SS ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# fj PERMIT VALID to 11 Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> 4 <br /> 23113 <br /> V23/13 MASTERFILE RECORD INFORMATION PINK <br /> 7 <br />