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SAN JQAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New F cility Facility ID !��2log S Program Record ID / L5 2 Facility Address 50 Void V4,,lm � 5jmk 3 UI 0-S?-(Z (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 ❑ 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# ticker# ❑ Temporary Food Facility–Dates of operation from to ❑ Ice lant❑ Produce Stand 11Special Event---Dates of operation from to CFO VA ❑ 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) ❑ PER 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 Housinv/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-NPL/SEP 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 ❑ 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 Co-ord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity r,Eblll HENT ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of UnREC_FIVEn SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ SludK4s j$te,2Q21 ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill SiteQUN7Y 1:1 Refuse Vehicles(#cf units) 11Dumpsters>20 cu yd (#of units) 11Fa�`�/i 6 4 p Site MEDICAL WASTE PROGRAM (4500) HEALTH DEPARTMENT ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON V4114 Ve—Vt Day Ph �_L{ j- JJ 3Night Ph PROGRAM ELEMENT FEE (/t/ ❑ Surcr e F E ❑ Other FEE INSPECTOR# PERMITVALID 20 t0 3 11 Food Handler ❑ Check# L� AMOUNT PAID — Date 2,,l INVOICE# 3 ❑ Cash REVIEWED BYAM S ACCOUNTING OFFICE Date MA/ 48-02-034 ](. ^' I� MASTERFILE RECORD NFORMATION PINK 1123113 %EY13-3 7 "C 1.