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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM M New EH Proqram at Existing Facility ❑New EH Program and New Facility II Facility ID14-1TI','LIUM) Proclram Record ID / II Facility Address 11'h tS- P�t mG(ffm CA T:;%lC5 (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 ❑ detail Market ---Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only Mobile Food Vehicle --Make Vehicle Type Color Registration # Z E rib H91TV7TIL License#jRhr;2 (O 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: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Hazardous Waste Generator (2200) -------->-Tons Generated Per Year ❑ Tiered Permitting Facility ------> OCA(2232) ❑ CE (2233, 2234, 2235, 2237) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program ❑ Program 3 Facility ❑ PBR (2231) ❑ PBR HHW (2236) 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 Event Mobile Facility (413 1) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration # License # Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets --Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Sitp 11 Refuse Vehicles (# of Units) ElDumpsters > 20 cu yd (a of units) ❑ FarmlRanch bq! %f7. MEDICAL WASTE PROGRAM (4500) a �. ,1 ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limi Haulerveill1 El Transfer Station El Veterinary Clinic ❑ Common Storage Facility 112 - 10 111, - 60 ❑ > 6? eot,fnrs,o PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form SAN Jr),,,, < Z2 CONTACT PERSON Day Ph L2�itfeS Night Ph -"Py 2994 PROGRAM ELEMENT_ 1U' CU FEE ❑ Surcharge �E I-]OtherFEE INSPECTOR # "I PERMIT VALID a' -a- to v�'ll i/ a-5: ❑ Food Handler ❑,Eheck # AMOUNT PAID Date INVOICE # , Nd Cash 16'1;' REVIEWED BYa ACCOUNTING OFFICE dIbLDate (S 2— 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13