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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑New EH Program at Existing Facility ❑New EH Program and New Facili FFacility ID Program Record ID Facility Address (o Iq 11 1 qac t4 , 06 q5 371c (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) 11 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES❑ No ❑ ❑ Commissary ❑ Dry storage only ❑with 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 to ❑ Ice Plant❑ Produce Stand ® Special Event—Dates of operation from 10/22/21 to 10/2212022 ® CFO 0 A ❑ B DAIRY PROGRAM (2000) ❑ Glade A 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 El Underground Storage Tank Program(UST)(2300)Use USTA 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 Housina/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP 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 _ ElPool El spa ElOut of Service Pool/Spa 11N M167 ilrea VECTOR CONTROL PROGRAM(4000) �ECEIVED ElPoultry Farm—Maximum number of birds ❑ ennel TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) OCT 2 7 2021 ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Si ngle Use (412 UNTY ❑ Body Art Facility-Sterilization(4121) ❑ Body Art Temp Event Coord(4130) ❑ Body Art-Temp EvM? 4131) LIQUID WASTE PROGRAM(4200) HEALTH DEPARTMENT ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units SOLID WASTE PROGRAM(4400) d Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd(#of Units) ❑ FamdRanch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑'Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station [] Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600)Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM CONTACT PERSON Mary Hood //--�� Day Ph 608-046-3733 Night Ph 608-446-3733 PROGRAM ELEMENT FEE I?7— ❑ Surcharge FEE ❑ Other FEE INSPECTOR# e PERMIT VALID ID to IO' I ' ❑ Food Handler 16 Check# -�1 AMOU TPAID >� 46 Date (� 7i I INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48.02-034 MASTERFILE RECORD INFORMATION PINK 123/13