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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Sip t+ p �VF� MASTERFILE RECORD INFORMATION FORM ❑New EH Program at Existing Facility 8 21 '�77�� ii New EH Program and New FacilitySAE'/OA Q(/ 20 Facility ID ��.ee619:7Q P ogram Re rd ID 5 72.7 HE NVIRD NCO Facility Address J J DEpgp 74� (Please check the appropriate description and specify size num er of units and pertinent i formatlon.I t MENT ,F OD PROGRAM(1600) Restaurant: Seating Capacity Square Footage 'L1?1 • Food Handlers Course required, Yes Commissary Ela onl Dry stora No [I9 Y ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market—Square footage ❑ W/Meat Market only ❑ Multiple Departments❑ Prepackaged 11 Mobile Food Vehicle–Make Goods Only ;I Registration# Vehicle Type Color ElMobile Food Prep Unit–Make License# Sticker# Registration# Vehicle Type Color EJ Food Facili p License# Sticker# ty–Dates of Operation from to ❑ ❑ Special Event—Dates of operation from Ice Plant❑ Produce Stand to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dai CUPA ry El Milk Dispenser-Number of Containers in Multi-Head Unit ❑ 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)x: ❑ Aboveground Storage Tank Facility(AST)(2800) Number of ASTs _ ❑ Underground Storage Tank Program(UST)(2300)Use UST A and B forms El Other CUPA Program i' HOUSING PROGRAM(2400) ❑ Hotel/Motel—Number of Units 11 Employee Housing(2700) Use Employee Housing/Labor Camp Application lForm l or ompt Institution —Number of Units 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 _ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa VECTOR CONTROL PROGRAM(4000) El Natural Bathing Area ❑ Poultry Farm—Maximum number of birds TATTOO BODYPIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Kennel ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art Facility-Single Use(4120) _ ❑ Body Art Facility-Sterilization(4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) - LIQUID WASTE PROGRAM(4200) ❑ Pumper VehicleRegistration# License# Capacity ❑ Pumper Yard ❑ Package Treatment Plant 11Chemical Toilets—Number of U tshicle# 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(pot Units) ❑ Dumpsters>20 cu yd O of units) ❑ Farm/Ranch 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 • E ER ENCY NOTIFICATION FOR THIS FAC TY AND/OR PROGRAM CONTACT PERSON Day Ph ) ?,Night Ph E RAM ELEMENT FEE n ❑ Surcharge FEE ❑ Other FEE TOR# \(� ('HERMIT VALID – GSI^2,� t0 �' .b_ 2'Z ❑ FOOd ck# AMOUNT PAID Date INVOICE#.h REVIEWED BY ACCOUNTING OFFICE 4Date •� 6-02-034 1/23/13 MASTERFILE RE RDI ORMATION PINK