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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH EPARTMENT MASTERFILE RECORD INFORMATION F M ❑ New EH Program at Existing Facility ew EH Program and New Facilit Facility ID CJ 210 Program Record ID Facility Address I I ✓! q,72t>3 (Please check the appropriate description and specify siz , 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 ❑ M 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 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 Housing/Labor 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 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 ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----NumberoRt� SOLID WASTE PROGRAM (4400) Ve. ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site /Ash Site 11Waste Tire Facility 11Compost Facility ElProcess/Recycle Facility CIA Af, ❑ Refuse Vehicles (#of units) ❑ Dumpsters> 20 cu yd(#of units) S (l inchanup Site MEDICAL WASTE PROGRAM(4500) HSC N0 IVMECNry ❑ Primary Care 11Acute Care ElSkilled Nursing ElLarge Generator ❑ Small Generat0 r4 Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02.003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/Oft PROGRAM CONTACT PERSON Day P — 0 6 3 ? Z Night P b Z PROGRAM ELEMENT 1 I X77 FEE ❑ Surcharge F ❑ Other FEE INSPECTOR#��1 PERMIT VALID t0 El Food Handler G- ❑ Check# AMOUNTPAID Date INVOICE# 3 4 ❑ Cash 8911 REVIEWED BYr ACCOUNTING OFFICE Date 4/23/13 4 ,'+-: I e�, I ^ '/t MASTERFILE RECORDINFORMATION PINK 1123/f3 /l�//}/yt�p/}IL'l- _[,jl