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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 Facility Facility ID 6021' Program Record ID RD Facility Address 3550 I`13 in1 ISOfJ 1..9/Mf 1'T) (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes ❑ Nox, ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market---Square footage ❑ w/Meat Market only ❑ Multiple Departments Xprepackaged 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 ❑ CFO ❑ A ❑ 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: ❑ 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 ❑ 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 Housinq/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Poo(/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm---..Maximumnumber 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 Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM (4200) P�,� ❑ Pumper Vehicle Registration# License# Capacity pt�. ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number 6Pdr�tsE��B SOLID WASTE PROGRAM (4400) R ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑`Slgdjellkjo2 to ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility S4 IjS�b ndfill Site ❑ Refuse Vehicles (#of units) ❑ Dumpsters>20 cu yd (#of units) aY9i ��NgQ1�{�NN anup Site MEDICAL WASTE PROGRAM(4500) HEALTH DEPgRTMENT ❑ 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 �t p + ' CONTACT PERSON S� EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PRO Legg-Ph'� I IQ D g' �1q I S PROGRAM ELEM NT- FEE 0 co rn`I, 7� ❑ Surchar FEE ❑ Other FEE INSPECTOR# Z PERMITVALID f. t0 �� 3 �Z ❑ Food Handler ❑ Check# AMOUN PAID 3S5 Date 6 2 INVOICE# Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECoRb INFORMATION PINK 1123113