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-F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facility Facilityy ID Program Record ID Facility Address 646b PINE t4t-�*900J Cat Sc-MC 7TAI CA- 851-1 (Please check the appropriate description and specify s e� number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant Seating Capacity Square Footage Food Handlers Course required: YES❑ No ❑ ECommissary ❑ Dry storage only Irwith Food Preparation Mending 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 Pla ❑ Produce Stand ❑ Special Event—Dates of operation from to �FO El 9B DAIRY PROGRAM (2000) ❑ Grade 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/MotelNumber of Units ❑ Jail or Exempt Institution—Number of Units Employee Housing(2700)Use Employee Houstna/L—bor 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-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 Coord(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/ Site ❑ Waste Tire Facility 11 Compost Facility 13Process/Recycle Facility 11 CIA La ❑ Refuse Vehicles I*of units) ❑ Dumpsters>20 cu yd 0 or units) [3Fa Ww$Ite MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generat��o�r''� I auler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 ❑ 11 -6(Fc_� „ Q60 e rs PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 4602-003 Blue Apprrcation Form ft ONM COUN EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM ?Zdw.9 qfCO�U l)' CONTACT PERSON AVN CON &7t-V1 BE Day Ph W X13593 Night Ph Zbo, c PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE IIN,SS ECTgR_A PERMIT VALID t0 q ❑ Food Handler LYJ G lc')""## 21JJ AMOUNT PAIDIND: Date -I ,37-I INVOICE# ❑ Cash 0/1 REVIEWED BY' 4kAACCOUNTING OFFICE Date 4802-034 MASTERFlLE RECORD INFORMATION PINK 1/13113