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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Prooram at Existino Facility ❑New EH Proaram and New Facilitv FacilityAddress 7199 Wu n u ar tAa(\k2Ca. CA. g5737 (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 W No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market ---Square footage ❑ with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle -Make Registration # ❑ Mobile Food Prep Unit Registration # ❑ Temporary Food Facility -Dates of operation from ❑ Special Event Dates of operation from DAIRY PROGRAM (2000) Vehicle Type Color License # Sticker # Make Vehicle Type Color License # Sticker # to to ❑ Ice Plant ❑ Produce Stand ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit CUPA ❑ State Facility Surcharge (2399) Pernalielftt'CLLPs (4122) HAZARDOUS WASTE PROGRAM (2200) PERMrr VALID ❑ Hazardous Waste Generator Tons Generated Per Year ❑ Recycle/Exempt System (2299) ❑ CRT Offsite Handlers (2218) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) ❑ landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use USTA and B forms HOUSING PROGRAM (2400) ❑ Farm/Ranch Cleanup Site ❑ Hotet/Motel—Number of Units ❑ Jail or Exempt Institution —Number of Units Employee Housing (2700) Use Employee Housinq/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility _ ❑ Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm—Maximum number of birds _ ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area PAYMENT RED&' TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) p� n nLfU1 ❑ Tattooing (4121) ❑ Body Piercing (4120) ❑ Pernalielftt'CLLPs (4122) LIQUID WASTE PROGRAM (4200) PERMrr VALID ❑ Pumper Vehicle Registration # License # Capacity t0 T1!kA 7-02-3,0 ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets —Number of Units SOLID WASTE PROGRAM (4400) Date - I/ 2 g / ❑ landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (#of units) ❑ Dumpsters > 20 cu yd (#of Urns) ❑ Farm/Ranch Cleanup 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 CONTACT PERSON Day Ph PROGRAM ELEMENT 1608 FEE 55ElSu/r�charrge FEE INSPECTOR#\ PERMrr VALID Z%i� �ZZ t0 T1!kA 7-02-3,0 18788 Check # V ( S A- AMOUNT PAID _ I J7 S ' Date - I/ 2 g / ❑ Cash REVIEWED BY ACCOUNTING OFFICE NightPh 2oq - G7q -SS8 q ❑ Other FEE C& Food Handler CA- 24 3 4 6150 INVOICE # Date 48.02-034 MASTERFILE RECORD INFORMATION PINK 11/15/07