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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Prociram at Existinq Facilitv ❑New, EH Prooram and New Facility <br />11 Facility ID f-1407[-(o/Ce6 Program Record lD I K At y 7 /G,y II <br />Facility Address5'01 E \M A 10 SJ • <br />"-74v-r-J <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FO D (1600) <br />Restaurant: Seating Capacity Square Footage <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 ❑ w/Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle -Make 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 />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200) --- - ----- >-Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PER HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel--Number of Units ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housin-g/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water,Qyaljty, pW,diation Site <br />RECREATIONAL HEALTH PROGRAM (3600) F'Ai I�YiCi4 1 <br />Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa RMENfighing Area <br />VECTOR CONTROL PROGRAM (4000) A n���' <br />❑ Poultry Farm ------Maximum number of birds SEE) en <br />TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) SAN JOAQUIN COUNTY <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Fa��?f0) <br />11 Body Art Facility -Sterilization (4121) El Body Art Temp Event Co-ord (4130) El Body Art -Temp vent o I e acuity (413 1) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # License # Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets —Number of Units <br />SOLID WASTE PROGRAM (4400) <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 wof 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 ❑ 2 - 10 ❑ 11-60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSONAaV-rI-Jts,/� IL N6t Ni)p (ILS Day Ph q0 - ` ) SI I UQ)Z Night Ph L,O 3 ) 5 y0 B 2 <br />PROGRAMS <br />INSPECTOR # <br />❑ Check # <br />PERMIT <br />AMOUNTI <br />❑ Cash REVIEWED BY (n� <br />48-02-034 <br />A <br />1//2311323/131M ,/� 011 Y^�L�tI�.J-�-- <br />FEE 'rr 5"-X T. ❑ Surcharge FEE <br />/ LvLI to <br />�— Date <br />ACCOUNTING OFFICE <br />❑ Other FEE <br />2-0 Food Handler <br />_ INVOICE # <br />Date q <br />MASTERFILE REdORZ INF <br />