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AF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facilit Facility ID Z Program Record ID PR Facility Address X421 PINF P✓l6fr"oOJ QIZ MCK7TAI CA- qyz/y (Please check the appropriate description and specify size,numberof units and Pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs❑ No ❑ 17�Commissary ❑ Dry storage only 01with 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 to13k�P-la�11 Produce Stand ❑ Special Event—Dates of operation from to �FO ❑ A I�e DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Mulli-Head Unit CUPA ❑ Hazardous 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) ❑ 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) 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 Cord (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 11Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA La fil�l El Refuse Vehicles Ix of unds) 13Dumpsters>20 cu yd (c of Units) ❑ Far a140e MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator �ti.I�rr FJfiuler ❑ Transfer Station ❑ Veterinary Clinic 11 Common Storage Facility 1:12- 10 11 11 -60` RAV r 60 ge rs PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46.02-003 Blue Application Form FM'/Rp UlN CO EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAMMF�NIT,.v( CONTACTPERSON i$& U.0h! bMt-IA13157 Day Ph ,2(J� �]i3 �/3�✓"S Night Ph PROGRAM ELEMENT FEE ❑ Surcha FEE 11Other FEE IN EC PERMIT VALID hQ f 10 9 ❑ Food Handler AMOUNT PAIDV Dafe 3 INVOICE# cadJ ❑ Cash REVIEWED BY' AL4 ACCouNT1Nc OFFICE OLOW Date ` O 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13