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-SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FARM ❑ New EH Program at Existing Facility New EH Program and New Facilit Facility ID =2,- Program Record ID 3 Facility Address le10 say-amza (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# ]- Sticker# � 7 11 Temporary Food Facility--Dates of operation from to El Ice Plan❑ 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: ❑ CaIARP 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 UST A 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 Cama 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(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper VehicleRegistration# 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 ❑ ProcesslRecycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd (#of units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) PA%- ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator git El Transfer Station El Veterinary Clinic El Common Storage Facility 112- 10 [1 11 -6o ❑ > is PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form DF EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM $�J � �O �O?' CONTACT PERSON V( l C f Day Ph alis fight Ph f OAQUI PROGRAM EEMENT 1:1 SurcharueFE 11 Other FE HDEPp ;�A INSPEc7 # PERMITVALID �2 to 1 .3120 :2-,' ❑ Food Handler I� a AMOUNT PAID 2 Date 612J INVOICE# ❑ Cash REVIEWED BY La V L2 ACCOUNTING OFFICE Date L212 2394 ERI RECORD FORMATION PINK 1/ 19p�, I II('^tel 1,1