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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> Now EH Program at Exlatlng Facility ❑New EH Prq ram and New Fac <br /> Faclllty ID r4 OOzZ,513 Proyrom Record ID Ra7w42-4lll <br /> Faclllty Address 1-q _ 5�A gijup <br /> (Please check the appropriate description and specify glbg,number of units and pertinent Information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant Seating Capacity_ SquareFoolege Food Handlers Course Ind: YES❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Unite <br /> ❑ Retail Market- Square footage ❑ w/Meet Markel only ❑ Multiple Departments❑ Prepackaged Goode Only <br /> ❑ Mobile Food Vehicle..Make Vehicle Type Color <br /> Registration# License If Silcker# <br /> ❑ Mobile Food Prep Unit.-Make Vehlole Type Color <br /> Registration# License# Slicker# <br /> ❑ Temporary Food Facility -Dates of operation from to ❑ Ice Plant❑ Produce Stand <br /> ❑ Special Event...Dates of operation from to ❑ CFO ❑ A ❑ B <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dalry ❑ Grade 9 Dalry ❑ Milk Dispenser-Number of Containers in Multi-Head Unit _ <br /> CUPA <br /> ❑ Hazardous Materials Business Plan(1900) Number of chemicals: <br /> ❑ CSIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator(2200)--------->-Tons Generated Per Year <br /> ❑ Tiered Permitting Facility------> ❑ CA(2232) ❑ CE(2233,2234,2236,2237) ❑ PER(2231) ❑ PER HHW(2236) <br /> ❑ Aboveground Storage Tank Facility(AST)(2500) Number of ASTs <br /> ❑ Underground Storage Tank Program(UST)(2300) Use UST A and B tonna <br /> ❑Other CUPA Program <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel----Number of Unite ❑ Jail or Exempt Institution----Number of Unite _...... _ <br /> Employes Housing(2700)Use Employee Houalna/Labor Camp Apallcaflon Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> yFjL►DUHCGtO(4000) <br /> Poultry ttry�4-------Maximum number of birds ❑ Kennel <br /> TATTOO,BODY PIERCING.PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Body ArtPractitioner Reg(4110) ❑ Mechanical DEPS Notification(4116) ❑ Body Art Facility-Single Use(4120) <br /> ❑ Body Art Faclllty-Sterilization(4121) ❑ Body Art Temp Event Co-ord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) <br /> LIy�{�y/p,;tTE P114rBDGM(4200) <br /> P❑ umper VehlcleReglelratIon# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets---Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles Is or unsa) ❑ Dumpsters>20 cu yd)s or unite) ❑ FormlRanch Cleanup Site <br /> (4600) <br /> Primary CareAcute Care 11 Skilled Nureing ❑ Large Generator ❑ Smell Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ >60 generators <br /> l;%UVaAX <br /> d <br /> (4600)Use PWS EHD 46-02-003 Blue ADollca#on Form <br /> CONTACT PERSON L9 a 1c r uN uR rDay Ph LI 4p uR h Ighl Ph <br /> LB.Id <br /> PROGRAM ELEMENT /6S.2— FEE _ ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR ���y PERMIT VALID S 2 to /o �- ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date Z INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date S-12, <br /> s D Afonvow <br /> 1pe11e <br />