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PA SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Rje CEANT MASTERFILE RECORD INFORMATION FORM EQ ❑New EH Program at ExistingFacility /flNew EH Program and New Facili DEC 3 p 20 Facilit ID Q7u Program Record ID `+ SqN J0q 21 �p��1 ENV/ QU/N C Facility Address lib y p 1p(� C . L WV cc, GIS 55 333 HEALTH�EPQRC7 NT (Please check the appropriate description and specify size,number of units and pertinent information.) mE FOOD PROGRAM(1600) ❑ Restaurant: Seating CapacitySquare Footage Food Handlers Course required: YEs'R 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# Sticker# ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event—Dates of opera0on from to ❑ CFO ❑A❑ B DAIRY PROGRAM(2000) / ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA O 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 UST A 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 HousinglLabor 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 Remedlation 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 VehicleRegistration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units 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(#of unlw) ❑ Dumpsters>20 cu yd(#cfunits) ❑ 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 EMERGENCY NOTIFICATION FOR THIS Fp?!!.TY AND/OR PROGRAM CONTACT PERSON Day P !],- L, ' !`Night Ph PROGRAM ELEMENT { r FEE ❑ Surcharg FEE ❑ Other FEE INSPECTOR# ERMIT VALID I 21-- t0 r 2 3 ❑ Food Handler ❑ Check# i97AMOUNT PAI Date _44INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 4802-034 MASTERFILE R.CORD INFORMATION PINK 123113 - - - - - - - -