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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />LMASTERFILE RECORD INFORMATION FORM <br />and New <br />I Facility ID /1 / Program Record ID <br />1220 Colony Rd, Ripon CA 95366 <br />R�cF AFD <br />N ASG <br />SA46 2021 <br />NFEWI <br />A TIYO� pgRVr,4ZV <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600)) (Drive thru only) <br />t,❑Restaurant: Seating Capacity 0 Square Footage 862 <br />Food Handlers Course required: YES ❑ No❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑Vending Machines Number of Units <br />❑ Retail Market --Square footage 0 ❑ w/Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑'IMobile Food Vehicle --Make n/a Vehicle Type <br />Color <br />Registration # License # <br />Sticker# <br />❑ Mobile Food Prep Unit-- Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />❑ Temporary Food Facility --Dates of operation from <br />to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to <br />(❑,'CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility <br />❑ Hazardous Waste Generator (2200) ---------- >-Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use USTA and B forms <br />❑ Other CUPA Program <br />❑ Program 3 Facility <br />❑ PBR (2231) ❑ PBR HHW (2236) <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housinu/Labor Camp Application 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 1:11 Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _ ❑ Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds_ <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration# <br />❑ Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />License # <br />❑ Package Treatment Plant <br />Capacity Vehicle #, <br />❑ Chemical Toilets ----Number of Units <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 (# of Units) - ❑ Dumpsters > 20 cu yd (# of Units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 11 -60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />509-392-1250 <br />PROGRAM ELEMENT FEE // ❑ surcharge FEE ❑ Other FEE <br />INSPECTOR# p;z?��7- Q` PERMIT VALID `� !O t0 O /3 Z ❑Food Handler <br />❑ Check # �-r'C 2I AMOUNT PAI �,�C/• Dpi Date 4 Z/ INVOICE # <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />1/23/13 <br />