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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facili ❑New EH Pr ram and =Facili Facili ID S Program Record ID Facility Address III ro(Ik i✓i L2vL2, LodCA q5Z-Y2 (Please check the appropriate description and specify gee,number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating CapacitySquare 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 aSpecial 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: ❑ 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 Storage Tank Facility(AST)(2800) Number of ASTs ❑ Underground Storage Tank Program(UST)(2300)Use UST A and B/orms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing(2700) Use Employee HousinalLabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP 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 ❑ Kennel TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) ❑ Body 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 VehicleRegistration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill S)U�,Q��//II-� ❑ Refuse Vehicles(#ofunb) ❑ Dumpsters>20cuyd (#of units) ❑ Farm/Ranct�Ipaj�Upp`@A,T MEDICAL WASTE PROGRAM(4500) CC((,,`F/ 'A El Primary Care 13 Acute Care ❑ Skilled Nursing 13 Large Generator ❑ Small Generator ❑ Limi UUHauler V ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ >6rjeehe��rs, PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form 341V�Oq r1,,, EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR P RA N fLNrVl�o• QUl CONTACT PERSON -t"t VhVXr V\Vi V1 I Day Ph Z�`7 7v 3X31 Night Ph ��'m g Nl1' PROGRAM ELEMENT FEE ❑ SurG a FEE ❑ Other FEE NT INNSSpECTOR# PERMIT VALID 2oZ t0 3� 1i ❑ Food Handler t"J Check# AMOUNT PAID - J Date I I VOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 7i 48-02-034 A TERFILE RE(WROINFfORMATION PINK 1/23/13