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t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Pro ram and New Facilit Facility ID �2G8 Program Record ID ftst ,32. Facility Address ' U S i f ✓i/'A S} (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 tail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only IKMobile 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 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) ❑ PBR (2231) ❑ PBR 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 Housing/Labor Camp Application 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-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 11 Body Body Art Facility-Sterilization (4121) Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobil Wacil LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets---Number of Units IVUY C [O SOLID WASTE PROGRAM (4400) SAN JOAQUIN COUNTY ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/AH NMENTAL ❑ Waste Tire Facility EI Compost Facility ❑ Process/Recycle Facility 0IA Landle DEPARTMENT ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd (#of units) ❑ 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 112- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600)Use PWS EHD 46-02-003 Blue Application Farm MERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSOh'r 'I Day P<Xq1tkNight P — PROGRAM ELEMENT FEE T> ❑ Surcha ge FEE ❑ Other FEE INSPECTOR# PERMITVALID Z t0 El Food Handler ❑ Check# �Sa-_ AMOUNT PAID '!`( Z Date I TIFE#_ ElCash REVIEWED BY ACCOUNTING OFFICE ate �Z 48-02-034 / /' MASTERFILE RECORD IN RMATION PINK 1/23/13 Lu �( b r l M UJ{ L (,q 11t-/N�3 t(�36/2-o Z/