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SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL <br />MASTERFILE RECORD INFORMATION <br />❑ New EH <br />Facility Address 12(`(J W ( (Gt-O ' S±. <br />(Please check the appropriate description and specify size, number of units and <br />FOOD PROGRAM (1600) <br />PARTMENT <br />M <br />�l Restaurant: Seating Capacity Square Footage 2150o Food Handlers Course required: YEs M No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # <br />❑ Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License #_ <br />❑ Temporary Food Facility --Dates of operation from to <br />❑ Special Event ---Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Color <br />Sticker # <br />_ Color <br />_ Sticker# <br />❑ Ice Plant ❑ Produce Stand <br />❑CFO ❑A❑B <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 ❑ 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) ❑ PBR 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 Housing/Labor Cama 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-NPLISEP Cleanup Site ❑ RWQCB 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) P pp NT <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) 11 Body Art Fa1•1 9V�1 120) <br />❑ Body Art Facility -Sterilization (4121) El Body Art Temp Event Coord (4130) 13 Body Art -Te acility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />11 Pumper Vehicle Registration # License # Capacity OCT 0 VehkfE <br />lf <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets---Ngirg��&PrOUNTY <br />SOLID WASTE PROGRAM (4400) ENVIRONMENTAL <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site HEA0,'R&%9//%WTite <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (# of Units) ❑ Dumpslers > 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 1:12 - 10 011-60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON LkV l Day P 1.05)7) 7-1-YONight Ph <br />PROGRAM ELEMENT FEEIQU <br />, / 11Surchagge FE ❑ Other FEE <br />INSPECTOR#� PERMIT VALID (7 �vI to LD( 2 11 Food Handler <br />❑ Check # /1 AMOUNT PAID a Date 0 INVOICE # <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE a&L Date <br />48-02-034 MASTERFILE RECOR5 INFORMATION PINK <br />1/23/13 <br />