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'SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM I PAYti1E El New EH Program at Existing Facility []New EH Program and New Facility Nr Facility ID r:AM2(,z'5-2—LProgram Record ID (� � VF� y ' �D s. Ali i)niq LL SMAS Z 'JZl Facility Address (Please check the appropriate description and specify size, number of units and pertinent information.) H fktjt? INCOUry FOOD PROGRAM(1600) �TH'DONYE 7_111 ry ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 8�Np ❑ ❑ 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 ile 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 8 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 Housing/Labor Cama 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 Vehicle Registration# 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 Site ❑ Refuse Vehicles v of units) ❑ Dumpsters >20 cu yd I#of Units) ❑ FarmlRanch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application Form 5� EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM / CONTACTPERSON h/l�Vh P Day Ph Z b O7F7 Night Ph e9D PROGRAM ELEMENT FEE 13Surcharge EE ❑ Other FEE INSPECTOR# ,�'}(�� PERMITVALID t0 I 31 ❑ Food Handler Check# AMOUNTPAID . ' Date Z INVOICE# Cash REVIEWED BY ACCOUNTING OFFICE Date Z /44-02-034 MASTERRLE RECORD INFORMATION PINK 1/23/13