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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE <br />❑ New EH Proaram at Existina Facilitv Dfiew EH Proaram and New Facilitv <br />11 Facility ID I -S Proaram Record ID II <br />Facility Address �Y12 F. VYIi✓lfIr PVP, S irl ti �52o5 <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 />P,Retail Market --Square footage 11w/Meat Market only ElMultiple Departments ❑ Prepackaged Goods Only <br />IV 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 <br />❑ Special Event ---Dates of operation from <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dalry <br />to <br />to <br />❑ Ice Plant ❑ <br />IJ CFO ❑A❑B <br />Produce Stand <br />❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility <br />❑ Hazardous Waste Generator (2200) -------->-Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) <br />O Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use USTA and B forms <br />❑ Other CUPA Program <br />❑ Program 3 Facility <br />❑ PBR (2231) ❑ PBR HHW (2236) <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel—Number of Units ❑ Jail or Exempt Institution ---Number of Units <br />Employee Housing (2700) Use Employee Housina/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site <br />❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa <br />❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds <br />❑ Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body <br />Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body <br />Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # License # Capacity <br />Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets <br />—Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site <br />❑ Sludge/As X'r <br />El Waste Tire Facility ❑ Compost Facility ElProcess/Recycle Facility <br />11 Refuse Vehicles I# of units) 13 Du Tipsters > 20 cu yd (# of units) <br />CIA Lano elo <br />11fJ����i.� <br />❑ Farm/Ranc Cftl8y&Anile <br />MEDICAL WASTE PROGRAM (4500) LL !d <br />❑ Primary Care El Acute Care 11 Skilled Nursing El Large Generator 11 Small Generator Limite8 R <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 -10 <br />❑ 11 - 60 ) QgApA ators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON Gcf-"r-D U IlQtUA OCA BS Day PhNight Ph (2-M'149' 17 OpPt <br />PROGRAM E M�E1NT_IL FEE ❑ Surchha ge EE ❑ Other FEE <br />INSPECT # I- PERMIT VALID to IO-' Z%J ❑ FoodHandier <br />L°f�aeekt#* W41IM$AMOUNTPAID <br />/� IO .� Date S 22 INVOICE #�/di2-D <br />1:1 Cash REVIEWED BY I A �t A 0 II <br />ACCOUNTING OFFICE I / Date �/ <br />1/23/13 <br />