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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility El New EH Program and New Facilit Facility ID Z21oo2y-iL4= Program Record ID Facility Address '�2�1)o s CalipZnia Sf 31Y,0017 g52-03 (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# Sticker# Mobile Food Prep Unit-Make Vehicle Type Color Registration# License# IE5 Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ P &duce 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: ❑ 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 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 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 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 Evenntt/��jVlgl�(g_Nry(4131) LIQUID WASTE PROGRAM (4200) 1�1LV"® EI Pumper Vehicle Registration# License# Capacity REGM ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of UPntits�o 20SOLID WASTE PROGRAM (4400) UES+ " ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ S)IIiIJ� LINTY ❑ Waste Tire Facility El Compost Facility ❑ Process/Recycle Facility ❑ IN�6NT ❑ Refuse Vehicles p of units) ❑ Dumpsters>20 cu yd (#of Units) ❑ It"-faR�i eanup 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 FACILITY AND/OR PROGRAM CONTACT PERSON AjjAtI I u H(AY A-IY\e.z Day Ph 6 Zj Night Ph PROGRAM ELEMENT 1105 FE �I ❑ Surchar F [I Other FEE INSPECTOR# ,�� PERMIT VALID 12 20 2-02-1 t0 I �'! 3/ 2 ❑ Food Handler ❑ Check# AMOUNT PAID -12Date I2 n; INVOICE# 3 L Cash REVIEWED BY ACCOUNTING OFFICE Date 2 ia e-02-034 MASTERFILE RE ORD INFORMATION PINK 1123113