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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 nio Program Record ID Facility Address �QOI SYI-ead W . M0^-r0 QA 05351 (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# 3-13M 1 Sticker# ❑ Mobile Food Prep Unit—Make Vehicle Type Calor 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) ❑ PER(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 COPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel---Number of Units ❑ Jail or 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 Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/As ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Lan Lbnt T 1:1Refuse Vehicles I#of units) ElDumpsters>20 cu yd I#of units) ❑ Farm/Rz Ch 11 MEDICAL WASTE PROGRAM(4500) ClCL' nn ❑ Primary Care 11 Acute Care 11 Skilled Nursing 11 Large Generator 11 Small Generatolt�mit!A 11 Transfer Station El Veterinary Clinic El Common Storage Facility ❑ 2- 10 ❑ 11 -60y4 qP,T8erafbts PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form 'o P,yRNNI}' EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON �al I( Q1 IPT Day Ph Night Ph 7 PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMITVALID I2- ZI t0 I 3112 02 2- ❑ Food Handler Vheck# AMO NTPAID .� Date 2- 2 INVOICE# as REVIEWED BYQ )j ACCOUNTING OFFICE Date 124�12 48-02-034 MASTERFILE RECOIRD INFOORMATION PINK 1/23/13