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SAN•JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT !! MASTERFILE RECORD INFORMATION FORM ❑ Nev)`EH Program at Existing FaciI4 ❑New EH Program and New Facili Facili ' IDL�n 8 J`� Pro ram Record ID Facil!ty Address US I Q Vt �'nC D e C C SCJ 9 SZ(q (Please check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating CapacitySquare 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 to FO,dA ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ` ❑ Hazardous Materials Business Plan(1900) Number of chemicals: ❑ Cal, RP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)—>-Tons Generated Per Year ❑ Tield 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 HousingA.abor Camp Application Form SITE MMGATTON(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 ❑ Pool ❑ Spa ❑ Out of Service PoollSpa ❑ 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) UQUID:WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehide# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles lx of units) ❑ Dumpsters>20 cu yd (sof unit&) ❑ Fam fRapch Cleanup Site MEDICAL WASTE PROGRAM(4500) /�'7 ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 ❑ 11 -60 / I>� PUBUC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form •,V EMERGENCY NOTIFICATION FOR THIS FACIIJTY AND/OR PROGRAM `S'`W•/O 2�ZJ CONTACT PERSON �I C Day Ph Night Ph[j -` AQV/ PROGRAM ELEMIFNTT ,W 26 FEE YP -75 ❑ Surcharge FEE ❑ Other FEE �Fpslprr'9C INSPECTOR# "L PERMIT VALID to ❑ Food Handle 11 Check# AMOUNT PAIDa� )� , � ./ Date 2INVOICE# 3 Zab3 ❑ Ca'Sh CW3 REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 ,,II�� C iy- �,3[1t�rG� G��y).1.'JT STERFlLE RECORD INFORMATION PINK 1123113 f' I nO/ (1 -µ�*� 17J 1 J�� ✓- 1��/� . . ..