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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility ID } n0Z(,2 j <br />Facility Address 510 01`.-C Dr <br />❑New EH <br />RecordlD <br />V 1 <br />536/6 <br />R 6 ZZ)0FC p <br />(Please check the appropriate description and specify size, number of units and pertinent information.) �JOAC ?, <br />'I CCMO�x""U""NTy <br />FOOD PROGRAM (1600) <br />H�WIt? <br />4F <br />-4No <br />EI Restaurant: Seating Capacity Square Footage <br />Food Handlers Course reguire :Od k 11 <br />lCommissary ❑ Dry storage only El with Food Preparation <br />❑Vending Machines Number of Units FNT <br />El Retail Market ---Square footage Elw/Meat Market only <br />El Multiple Departments 1:1 Prepackaged Goods Only <br />❑ Mobile Food Vehicle --Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />El Mobile Food Prep Unit-- Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />❑ Temporary Food Facility —Dates of operation from <br />to C1 Ice Plant ❑ Produce Stand <br />El Special Event --Dates of operation from to <br />0 CFO *0 A El <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy El Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP Program 1:1 Program 1 Facility ❑ Program 2 Facility <br />El Hazardous Waste Generator (2200) -------->-Tons Generated Per Year <br />C1 Tiered Permitting Facility ------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) <br />El Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use USTA and B forms <br />El Other CUPA Program <br />1:1 Program 3 Facility <br />❑ PBR (2231) ❑ PBR HHW (2236) <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel ---Number of Units El Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housino/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />[I Environmental Assessment E]UST-CAPSite IJ Local HW Cleanup Site ElNPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site 11non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _ 11 Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds_ <br />❑ Spa ❑ Out of Service Pool/Spa El Natural Bathing Area <br />El Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) 1:1 Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) El Body Art Temp Event Coord (4130) El Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />[I Pumper Vehicle Registration # <br />❑ Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />License # <br />❑ Package Treatment Plant <br />Capacity Vehicle # <br />El Chemical Toilets ----Number of Units <br />❑ Landfill ❑ Transfer Station ElAg/Cannery Waste Site 11Sludge/Ash Site <br />El Waste Tire Facility ❑ Compost Facility ElProcess/Recycle Facility 11 CIA Landfill Site <br />❑ Refuse Vehicles (# of Units) ElDumpsters > 20 cu yd (# of units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care El Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic 11 Common Storage Facility ❑ 2 -10 1:111 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT <br />PROGRAM ELEMENT'.'. �. o-' �' <br />INSPECTOR #— S%b a <br />FEE <br />Check # AMOUNT P� <br />Cash REVIEWED BY \, (-1I✓ <br />IS Day Ph <br />�� L - ❑ Sm <br />124 to _ <br />.07� Date <br />ACCOUNTING OFFICE <br />Ph(20`I)y01 -6003 <br />❑ Other FEE _ <br />❑ Food Handier <br />INVOICE# 3(�2 <br />Date /L//Z7 <br />