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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Proqram at Existing Facilitv ❑New EH Proaram and New Facility 11 Facility ID 7 AOOZ7 /ZZ Program Record ID '42kn.i47(�� I Facility Address Q?oI �5�Li� (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 It No ❑ ❑ Commissary ❑ Dry storage only Erwith Food Preparation ❑Vending Machines Number of Units 0^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 # ❑ Temporary Food Facility —Dates of operation from to ❑ Ice Plant ❑ 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 Housino/Labor Camp 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-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 ❑ 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 1pofYfw"pity (4131) LIQUID WASTE PROGRAM (4200) RECe��D ❑ Pumper VehicleRegistration # License # Capacity ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ---Number pi{dn 13 2022 SOLID WASTE PROGRAM (4400) H�1( I ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site sAQ ,Ii Afto"t9L4 vy ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility 111NSMbi0MNT&e ❑ Refuse Vehicles (#of units) ❑ Dumpsters > 20 cu yd (# of Units) Ht'F#hl1Wt&i TM1nup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 11 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT 16a4 FEE 55 . OU ❑ Surch re F 11 Other FEE INSPECTOR# ,ti PERMIT VALID 13 L2— toiw 11 Food Handler ❑ Check # �iti AM/OVUUNTT PAID k 3 0� Date2� INVOICE# 3(-S- 0 Cash REVIEWEDBY �.d" — ACCOUNTING OFFICE Date /9ZZ 9&UL-0 1/23/13 34 _ (� C l `1a z� Zi MASTERFILE RECORD INFORMATION PINK (�Il+lam