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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 Program Record ID Facility Address 5A-k3 Vjn,d V41y.,o f. ()I MSZI 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# 11Mobile Food Prep Unit-Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility-Dates of operation from to / ❑ Ice lant❑ Produce Stand ❑ Special Event---Dates of operation from to IY 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 ❑ Tided 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 ❑ Jailor Exempt Institution ----Number of Units Employee Housing(2700) Use Employee Housing/Labor Camp Application Form 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 ❑ 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 'RAYWENT ❑ Pumper Yard - ❑ Package Treatment Plant ❑ Chemical Toilets—Number of UnRECEIVED SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ SludK4sj$te2021 ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site 7y El Refuse Vehicles(#of Units) ❑ Dumpsters>20 cu yd (#of Units) El / � 1 Cep 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 ❑ 2- 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 PERSONV-e44 / I /�/i, ` /1 Day Ph__*j- 4k7- .3 &3Night Ph PROGRAM ELEMENT U FEE 1 vU ❑ Surchar}�e FEE ❑ Other FEE INSPECTOR# PERMIT VALID t� 11 ZO Z( t0 t O( 3) 2.0 22 ❑ Food Handler ❑ Check# V��a-- AMOUNT PAID 1 Date LVID 2i0 / INVOICE# ❑ Cash REVIEWED BY S ACCOUNTING OFFICE Date 48-02-034 �I c) I� O MASTERFILE RECORD INFORMATION 14 PINK 1/23A3 =tom L 5 `( I.