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SAN J'OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ,O New EH Program and New Facilit Facilit ID fAcO2-6,517 Pro ram Record ID 2� Facility Address J 5 c v C � cA (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 ❑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 At Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant ❑ Produce Stand ❑ Special Event---Dates of operation from to CFO ❑ A-H't 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 USTA 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 Housina/Labor 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 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(#of Units) ❑ Dumpsters> 20 cu yd (#of Units) ❑ Farm{Q�nc Cleanup Site MEDICAL WASTE PROGRAM (4500) Ih-'A `jaller❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generatotf--]�>'46 ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 1:12- 10 ❑ 11 .60tors �t PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form EMERGE CY NOTIFI CAT FOR THIS FACILITY AND/OR PROGRAM SAN JOA 2, CONTACT PERSON 1 Day Ph G Night P . l ilhQU/N CO PROGRAM ELEMENTFEE v ElSurchar e FEE ❑ Other FEE P�TMEIvT INSPECTOR# PERMITVALID t0 513112-2— ❑ Food Handler ❑ Check# AMOUNT PAID . Date Iq Z( INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE AA Date �j 2 034 t� .I� ^ �^/ 1 MASTERFILE RECORD IFORMATION PINK 1/23/1 1/23/13