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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 Facilit Facility ID f FA Z2- - Program Record ID 7 kP Facility Address J AV) e Si- 2> OA ME (Please check the appropriate description and specify Rize, 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 # Sticker # ❑ Temporary Food Facility --Dates of operation from to _ - A ❑ Ice Plant ❑ Produce Stand ❑ Special Event --Dates of operation from to XCFO ❑ AOB 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: ❑ CalARP 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 Housing/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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area ❑ 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 # ❑ Pumper Yard License # ❑ Package Treatment Plant Capacity Vehicle # ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) w 11 Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site 1:1Sludge/Ash S�Ayj�e ❑ Waste Tire Facility 1:1 Compost Facility 11Process/Recycle Facility 11 CIA LandfillC�Q�7 11 Refuse Vehicles (#of units) ❑ Dumpsters > 20 cu yd {# of units) ❑ Farm/Ranclh eaM D MEDICAL WASTE PROGRAM (4500) OtC 1 9 EI Primary Care 11 Acute Care 11 Skilled Nursing El Large Generator ❑ Small Generator �Jy�1'ted Madle.�OZJ 1:1 Transfer Station ❑Veterinary Clinic ❑Common Storage Facility ❑ 2 - 10 011-60 El gtErOsU PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form HEatiri p p'NENT ii EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON{?VtiUOYVIC-dt✓tte( � Day Ph Ca04)0. j(*NightPh 8fo 4gjf{ PROGRAM EL4MENT I i U �1 FEE Li ❑ Surc ge EE ❑Other FEE INSPECTOR# W-11 PERMITVALID Z to ❑ Food Handler hh i ❑JChec #�L p AMOU PAID Vo Date ZZ INVOICE# S Casli%N11�D BY ACCOUNTING OFFICE Date 2.SZ.Z- 1/23113