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-SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existing Facility ew EH Program and New Facility <br />Facility ID r OhZ7DG-� Program Record ID <br />Facility Address IOW, 1 1?Wt-L1Yldf'i LD(,1.1'�� (+') In GV -r <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: YEs3� No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />❑ Retail Market—Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle -Make Vehicle Type Color <br />Registration # <br />❑ Mobile Food Prep Unit- Make <br />Registration # <br />❑ Temporary Food Facility -Dates of operation <br />❑ Special Event --Dates of operation from <br />DAIRY PROGRAM (2000) <br />License # <br />Vehicle Type <br />License # <br />to <br />Sticker # <br />Color <br />Sticker # <br />to 111 Plant 11 Produce Stand <br />3KCFO A ❑ B <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200) -------->-Tons Generated Per Year <br />❑ Tiered Permitting Facility —> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑PBR (2231) ❑ PBR HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B fors <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel -----Number of Units ❑ Jail or Exempt Institution --Number of Units <br />Employee Housing (2700) Use Employee HousinalLabor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) P�FAfY�ME�/ T <br />Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Na&3 Qhin Area <br />VECTOR CONTROL PROGRAM (4000) 2 4 FEB2022 <br />11PoultryFarm—Maximum number of birds Kennel <br />TATTOO- BODY PIERCING- PERMANENT COSMETIC PROGRAM (4100) <br />r7) n 7)i rni+i rnen . <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # <br />❑ Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />License # <br />❑ Package Treatment Plant <br />Capacity Vehicle #, <br />❑ Chemical Toilets --Number of Units <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (# of Units) ❑ Dumpsters > 20 cu yd (# or Units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 -10 1311-60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 4602-003 Blue Application Form <br />CONTACT <br />PROGRAM <br />FEE <br />INSPECTOR # -7/Y---/-) PERMIT VAL <br />,� <br />,Check #I D L) AMOUNT PAID <br />❑ Cash REVIEWED BY <br />48-02-034 <br />1/23/13 <br />Day Ph <br />❑ Su <br />to _ <br />— Date <br />ACCOUNTING OFFICE i <br />Night Ph Z V'i H s <br />❑ Other FEE _ <br />❑ Food Handier <br />Date <br />PINK <br />