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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Praamni at Fidstino Fadllty ❑ New EH Promam and New Facility Record ID RFCF ��r MAY 10 SA Facility Address 32-1/bUu}{,S{pc ♦•O�. ,,Zy— l� K C;4- 9f9-DbH ENV�gQUIN 20 21 -vie, (Please check the appropriate description and specify size, number of units and pertinent InformOn-)EACTFR�N%EfENOUIVTi' FOOD PROGRAM (1600) []Restaurant Seating Capacity_ SquareFootage Food HandlersCourse required: Yes ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market quare 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 fmm to ❑ Ice Plant ❑ Produce Stand 14 Special Event—Dales of operation from to ❑ CFO ❑ A ® B DAIRY PROGRAM (2000){•h �Sc'll ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemimis: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator (2200Y> -Tons Generated Per Year []Tiered Permitting Facility—> OCA(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 USIA and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ HoteUMotel—Number of Units ❑ Jail or Exempt Institution —Number of Units Employee Housing (2700) Use Employee HousinglLabor Camp Application Fomr SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP 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—Mawmum numberof birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENTCOSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ MechanlwI DSPS Notification (4115) ❑ Body AR FacililySingle Use (4120) ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Coord (4130) []Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration # License lt 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 (# of units) ❑ Dumpsters > 20 cu yd V or 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 112 - 10 1311-60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Forth CONTACT PERSON TC Day Night PROGRAM ELEMENT 1 h� FEE _ 'J (U — 0 SIAC11a•ge Fff ❑ Other FEE _ INSPECTOR# L% r PERMIT VAD S - (I ' 2 tD S- I 2- ❑ Food Handier ❑ Check#y;AMouNrPA _ d0. 0-S Date S /� INVOICE# ,ZS. ❑ Cash Date Scanned with CarnScanner r t