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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION ❑ New EH Program at Existina Facility IfNew EH Program and New FacilitV II Facility ID 1�14,�62/03(v Procram Record ID II Facility Address_ 5'Jq W 1)2 MA\0 V3 Ly7 HER k I of -I JR- BL_ v D S>oCKiofv 0&00 (Please check the appropriate description and specify size, number of units and pertinent Information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑ Retail Market ---Square footage ❑ w/Meat Market only ❑ Mobile Food Vehicle --Make Vehicle Type Registration # License #_ ❑ Mobile Food Prep Unit-- Make Vehicle Type _ Registration # License # _ ❑ Temporary Food Facility —Dates of operation from ❑ Special Event ---Dates of operation from to DAIRY PROGRAM (2000) Food Handlers Course required: YES ❑ No ❑ ❑Vending Machines Number of Units ❑ Multiple Departments ❑ Prepackaged Goods Only Color Sticker # Color Sticker # a ❑ Ice Plant ❑ Produce Stand ❑CFO ❑A❑B ❑ 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 ❑ Program 3 Facility ❑ Hazardous Waste Generator (2200)-------> -Tons Generated Per Year ❑ Tiered Permitting Facility ------- > ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PER HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs EIREC ME UUnderground Storage Tank Program (UST) (2300) Use UST A and B forms of T ElOther CUPA Program EIVED HOUSING PROGRAM (2400) 11 JAM 202,2 Hotel/Motel-----Numberof Units ❑ Jail or Exempt Institution ---• Number of Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SAN JOAQUIN COU SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) gENVIRONME NTy ❑ Environmental Assessment EI UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup SI eLTH P� t ENVIRONMENT LNT ❑ Abandoned HW Site ❑ non-NPUSEP 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 FacititySingle 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 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 Site ❑ Refuse Vehicles (# of Units) ❑ Dumpsters > 20 cu yd (# of Units) ❑ 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 Ph 012a-ySjl—iDIZ Night Ph LIP OGRAM ELEMENT kb1pct FEE L5,1 ❑ SurChar FE ❑ Other FEE PECTOR # ,S� PERMIT VALID - Zai - 2.2 to 3 30 L', ❑Food Handler Check #AMOUNT PAID . Date 3 �Z INVOICE# �3� 7 Cash REVIEWED BY i,UVnj S • ACCOUNTING OFFICE / Date 3/3/A, --,z �Sa34o� MASTERFILE RECORD INFORMATION PINK 23/13