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SAN JOAQUIN COUNTY ENVIRONMEN rAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM Neu EH Prct ram at Existing Facility ❑Nein EH Pro ram and New Facll,t Facility F 9 ooz6 m Program Record 10 7� Facility Address ?-3 i5-2O�I (Please check the appropriate description and specify,,number of units and pertinent Information.) Commissary (1600) Restaurant: Seating Caracity_ Square Footage Food Handlers Course required: YES❑ No ❑ ' ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vsndiny fdachlnesNunTber of Units ❑ Retail Market---Square footage ❑wi%leat Market only ❑ Multiple Depiaments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make__ Vehicle Type Color - Registration# License# Sticker# ❑ Mobile Food Prep Unit—Make _ Vehicle Type Color Rdgislralion# License# Sticker# _ ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Produce Stance ❑ Special Event--Dates of operation from to .___. ❑ CFO ❑ A ❑ B DAIRY PRQjGRA[d(20LL01 ❑ Grade ADairy ❑ Grade 8Dal ry El Milk Dispenser-Nie• .crofCoMik;nersinFAulfi-IteadUn.t __ CVUPA ❑ Hazardous Materials Business Plan(1800) Numb_r of chemicals. __ ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)---------->-Tons Generated Per Year Cl Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE(22:13,2234,2235,2237) ❑ PBR(2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST)(2800) Number of ASTs__ ❑ Underground Storage Tank Program (UST)(2300)Use WA and B forms ❑ Other CUPA Program HOUSING PROGRAM(24-00) ❑ HoteUMotol------Number of Units ❑ Jail or Exempt Institution----Number of Un Is _ Employee Housing(2700)Use Employee Housing/LRher Camp Ap 1 catio Form SITE MITIGATION(2900) Uf1DERGROUt•1D INJECTION CONTRA(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 Remedialfon Site RECREA1.IONAL HEALTH PROGRAM(3600) Number of PoolstSpas at Facility _ ❑ Pool ❑ Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area V CE TOR COfITROL PROGRAhl(4000) ❑ Poultry Fann......Maximum number of birds ❑ Kennel TATTOO BODY PIERCING PERNAN£NT COSMETIC PROGRAFA(4100) ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art Facility-Single Use(4120) ❑ Body Art Facility-Storilizatlon(4121) ❑Body Art Tamp Event Co-ord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper VehlcioReglstrallon# License# Capacity Vehicle;t ❑ Pumper Yarri ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ AglCannery Waite Site ❑ Sludge/Ash Site ❑ Waste Tiro Facility ❑ Compost Faclllty ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles In of un lc) ❑ Dunpsters>20 cu yd is or un u) _--- - _ ❑ FarinfRanch Cleanup Site NIEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ VeterinaryClinle ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ >60 generators PUBLIC MATER SYSTEM PROGRAM (4500) Use PWS EHD 46-02-003 Blue Application Form E'IEROENCY OTtfCATI NFORTHIsFACILITYAND13RPROGRA pyo CONTACT PERSON l r Day Ph r 1%iyht Ph � '��f ' b PROGRAM ELEMENT�r�p3 Y FEE ❑ Surcharg FEE CI Other FEE INSPECTOR#Y/ �L hr7 PEHLIITVALIO 9 to O ❑ Food Handler ❑ Check# AMOUNT PAID Dale INVOICE# ❑ Cash REVIEWEoay Accominf1,OFFICE DBIe 48-02-e14 MASTERFILERLC(RD 11'ORMArION PIriR L23113