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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH <br />Facility ID FA6026`72.3 Program Record IDi'(CQS`F73G`) 1 <br />FacilityAddress4142 F,.Morada Ln,&tOOY- vhf (A CA521'L- <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity _ Square Footage Food Handlers Course required: YEs ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number, of Units <br />❑ Retail Market—Square footage ❑ with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle -Make Vehicle Type Color <br />Registration # License # Sticker# <br />❑ Mobile Food Prep Unit Make Vehicle Type _ _. Color <br />Registration # License # Sticker # <br />❑ Temporary Food Facility -Dates of operation from to <br />❑ Special Event Dates of operation from to <br />_ ❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />COPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />❑ Hazardous Waste Generator --Tans Generated Per Year ❑ Recycle/Exempt System (2299) <br />❑ CRT Offsite Handlers (2218) --_ ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) <br />Tiered Permitting Facility --- 13 Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste <br />❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and 8 forms <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel —Number of Units ❑ Jail or Exempt Institution —Number of Units <br />Employee Housing (2700) Use Employee HousinalLabar Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600)t�,� <br />Number of Pools/Spas at Facility _ Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm—Maximum number of birds _ <br />❑ Spa <br />TATTOO. BODY PIERCING. PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (4121) ❑ Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper VehicleRegistration # <br />❑ Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />License If <br />❑ Package Treatment Plant <br />❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />Capacity Vehicle # <br />❑ Chemical Toilets —Number of Units <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ SludgelAsh Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles I# of Ueh) ❑ Dumpsters > 20 cu yd p of units) ❑ FarnlRanch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11-60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACTPERSON <br />Day Ph <br />20q 7-0-:t. 7,L3 <br />PROGRAM ELEMENT 3(0 I 1 FEE 4-Y 13 Surcha FE ❑ Other FEE <br />INSPECTOR# bm';ci A , PERMITVALID Z to JZ � ❑ Food Handler <br />❑_Check_#_ /.Sc,- AMOUNT 2- 2$3•oc5 Date /442/ INVOICE# 2 <br />❑ Cash REVIEWEDBY ACCOUNTING OFFICE <br />Q Date 2 <br />4&02-034 / 3I 0 5-01) 0 MASTERFILE RECORD INFORMATION PINK <br />11/15107 <br />