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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑$law EH Program at Existing Facility ❑New EH Program and New Facility Facility ID Program Record ID Facility Address 200 Neirloory-) .4v-e , Loth , CA 6152y 2 (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 [Wending 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 11 Ice Plant 13 Produce Stand Special Event--Dates of operation from to ❑ CFO O�{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 B forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel--Number of Units ❑ Jail or Exempt Institution----Number of Units Employee Housing (2700) Use Employee HouslnpILabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of PDOls/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 (412 1) ❑ 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 SOL16 WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludg �ENT ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA L �v]�/�, ❑ Refuse Vehicles(#ofunits) ❑ Dumpsters>20 cu yd (#cfUnits) ❑ Farm/Ranch Cleeaann�ite MEDICAL WASTE PROGRAM (4500) APR p 13Primary Care ElAcute Care 13Skilled Nursing 13Large Generator 1:1Small Genera Imited H a��r 13TransferStation 11 Veterinary Clinic 11 Common Storage Facility ❑ 2 -10 1111 -60AM�i@t>Nrs PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form HEALTH DEPMgRNTAL EMERGENCY NOTIFICAT ON FOR THIS FACILITY ANDIOR PROGRAM CONTACT PERSON K h Day Ph )3.20-76,70 Night Ph (!W&) 3-x0'7C7 b PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE I,NSSpECTOR# PERMITVALID t0 �t �1 13 Food Handler J Check# �— AMOUNT PAID A�_ Date '1 [i1 INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE RV7V Date 036 /231/ 1 3 MASTERFILE RECORD INFORMATION PINK C 1123/1 J