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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM JA ❑ New EH Program at Existing Facility ONew EH Program and New Facilit 4Z6��f� � Facili ID Program Record ID ./uz Facility Address '151 lA lel a yrt ecr �,�� czv t 1 etagQ��9R6 (Please check the appropriate description and specify size, number of units and pertinent information.) Nfq��/RON NCOU FOOD'PROGRAM(1600) TNOF MFNTAC ry ❑ Restaurant: Seating Capacity—n-L2- Square Footage Food Handlers Course required: YEsff❑ ❑ 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# Sticker# ❑ Temporary Food Facility-Dates of operation from to �} Ice Plant El Produce Stand 11 Special Event--Dates of operation from to ��,\\\ /\gdCFOXA 11B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA; ❑ Halzardous Materials Business Plan(1900) Number of chemicals: ❑ CalARP 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) i, ❑ Environmental Assessment 11 UST-CAP Site 11 Local HW Cleanup Site 11NPL/SEP Cleanup Site ❑ UICiSite ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) 1 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 VehicleRegistration# 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/Ranch 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 EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM ` CONTACT PERSON t t i Day Ph 96q-4'10 a.-Ic Night Ph ;�ocl 4-10 a��f PROGRAM ELEMENT — FEE 1W I ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMITVALID �'.c- t0 ❑ Food Handler 11Check# AMOUNT PAI 1,55,6 S Date -712- INVOICE# ❑ Cash REVIEWED BYACCOUNTING OFFICE Date - 48-02-034 - r, ry�� -y MASTERFILE RECORD INFORMATION PINK 2 1/23/13 J