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R �6ve0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT O/�� <br />MASTERFILE RECORD INFORMATION FORM ((.• 112021 <br />D New EHP rem M Edwtmg Facility ON.EHP remand New Facll <br />Faelll ID Pm nm Record ID <br />�OAQUIN p <br />2 N NVIRONM OUNTY <br />Facility Acidness f 1 PLA 531 EALTN pEP ENTAL <br />(Please Ula lk gle appropriate description am specify pjg, number of units and pertinent Interrogator) A"'Me)Vr <br />FMI) PROGRAM (1600) _ <br />D Restaurant Seating CapacM_ SgVare FwWpe Food Handlers Course remelted Y" El No filar <br />WWammissary D Cry storage only illFood Preparation OVending Machines Number of Units_ <br />O Retail Market -Square fwtage D vNMeat Market only D Multiple Departments O Prepackaged Goods Only <br />D Mobile Food Vehicle -Make Vehile Type Color <br />Registration# license# Sticker# <br />D Mobile Food Prep Unit -Make VeliceType Color <br />Registration# license# Sticker# <br />❑Temporary Fwtl Facility -Dares of operawnfrom to ❑ wam D Produce Stand <br />O Speclel Event—Dates or operation from to to CFO A ❑ B <br />aNRV PROGRIM <br />(HOD) <br />O Greta A Dalry D Gracie B Dalry O Milk Dlspeneer-Numberof Containers in Mulb- ead Unit <br />SUPA <br />O H ... maim Mandels Business Plan (1900) Numherof chemicals: <br />D CaIARP Program D Program 1 Facility D Program 2 Facility O Program 3 Facility <br />O HaeaMPUa Wash Generator (2200)—> -Tons Generated Per Year <br />O Tiered Pem, bfing F0cIllty—> OCA (2232) OCE (2233, 2234, 2235, 223_ D PSR (2231) D PBR HHW (2238) <br />D Aboveground Storage Tank Facility (AST)(2800) NumberWASTs <br />O Underground Stange Tank Program (UST) (2300) Use =-A AMR forms <br />D Other CUPA Program <br />HOUSING PROGRAM„ (2400) <br />O Hoteledotel --Number of Units D Jell of Exempt Institution —Number of Units <br />Employee Housing (2700) Use Em I No sl Q&abo Camp Application Form <br />SITE MITGA7I011(2900) UNDERGROUND (3000) <br />O Environmental Assessment O UST -CAP Site D Local "Cleanup Site D NPUSEPCIeanup She O UIC Site <br />D Abandoned HW Site O non-NPUSEP Cleanup She ORWO 13 Cleanup Site D Water Quality Remedlatlon Site <br />RECREATIONAL HEALTH(3 ) <br />Number of Pcals/Spes sl Fallity _ D Pool D Spa O Out a Service Pool/spa D Natural Setting Area <br />VECIORCONTROLPROGR4X(40W) <br />O Poultry Farm --Maximum number of birds D Kennel <br />TATTOO BOOV P "(4100) <br />OBody ArtProcthloner Reg(4110) DMechanical OSPSNctircellon(4115) O Body An FacllitySingle Use (4120) <br />D Body Art Fecillty-Stedildadan (4121) O Sady AR Temp Evem Coati (4130) D Body Ad -Tamp Event ll Facility (4139 <br />LIQUID WASTE PROGRAM (CM) <br />❑ Pumper Vehiclettegisbation# License# Capacity Vehicle <br />C3 Pumper YAM D Package Treatment want D Chemical Toilets—Number of Units <br />SOLID WAST: PROGRAM (4 ) <br />D Landfill D Transfer State. O AglCennery, Waste She D Sludge/Ash Sha <br />O Waste Tire Facility Cl Compact Facility O Process/Recycle Facility O CIA Landfill Site <br />D Refuse Vehicles Pal wMl O Dumpsters> M cu yd patwul _ O Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (45001 <br />D Primary Care D Acme Care O Skilled Nursing D Large Generator O Small Ganershr D Limited Hauler <br />D Transfer Station D Veaerli Clinic O Common Stange Facility D 2 -10 D 11 -W O > So penerators <br />MRAM (4800) Use PWS EHO 48-024I0.0 Blue Application Faro <br />I d1yQK eaax TR o THIS FA MLI I �1/les <br />CONTALT PERSON I C t�av vx✓`i�� <br />PROGRAM ELEM NT FEE,* IhVJ IAy D Surcharge FAP D Other FEE <br />how,sc <br />'VAU <br />ElcreiaM#--_.-__ PERMITARJ�p) ec --- Io T' INMCE Handier <br />❑ancone a AMOUNT PAR) �,j Data INVOICE# <br />