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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑New EH Program at Existing Facility IftNew EH Program and New Faclli Facility ID 2 P ram Record ID 3 Facility Address NIO C-w(Ae I i,r7 4 , te . `/S51A, (Please check the appropriate description and specify size,number of units and pertinent Information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating CapacitySquareFootage Food Handlers Course required: YEs o 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 A ❑ Mobile Food Prep Unit-Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility-Dates of operation from to 13 lee Plant❑ Produce Stand 13 Special Event-Dates of operation from to. ^ CFO 14A❑ B DAIRY PROGRAM(2000) _ ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit _ CUPA ❑ Hazardous Materials Business Plan(1000) 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—> OCA(2232) ❑ CE(2233,2234,2235,2237) ❑ PBR(2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST)(28110) Number of ASTs ❑Underground Storage Tank Program(UST)(2300)Use UST A and B forms ❑Other COPA Program HMMG PROGRAM(2400) ❑ HotellMotel—Number of Units ❑Jail or Exempt Institution—Number of Units Employee Housing(2700)Use Fmpfoyee HousinWU-borCampApplication Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(30D0) ❑ Environmental Assessment ❑ UST-cAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remedhtion Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at FaaTdy _ ❑ Pooi ❑Spa ❑Out of Service PooVSpa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm--Aa,dmum number of birds ❑ Kennel TATTOO.BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art Facility.VF ��120) 13o Body Art Faeflity-Stedlization(4121) ❑Body Art Temp Event Cord(4130) 13 Body Art-Temp Eq2 a Facility(4131) LIQUID WASTE PROGRAM(4200) .�// 11 ❑ Pumper Vehicle Registration# License# Capacity i1A-� aldse a ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number olyp'dspul. - SOLID WASTE PROGRAM(4400) n�`r�NOGaarr.,o� ❑ Landfill ❑Transfer Station ❑ Ag/Cannery Waste Site ❑ SludgelAsh Site ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(P counts) ❑ DUmpsters>20 CU yd(rd Units) ❑ FarnfRanch Cleanup Site Mg=—Al W ASM e_eOGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑Transfer Station ❑VeterinaryClink ❑ Common Storage Facility ❑ 2-10 Oil -60 ❑ f%wgene PUBLIC WATER$YSTEJII PROGUM(4600)Use PWS END 4802-003 Blue Application Form �)010�p� /_ No Tm FOR F CI .era/oR PROGRAM r 6 CONTACT PERSON 1 � a �� Day P S C -2 Nigh Ph PROGRAM ELEMENT JK� FEE 31' ❑ surcha F ❑ Other FEE le1SPECTOR# L�Ahu!`e,� PERM VAUD 5'/13 10 ❑ Food Hanler 13 check s AMounpAnAl° � ' Date 5� / ran Y'Z INVOICE# 3% - ❑ Cash REtMw® �( • 2.a- AcCOUNnmGOFFVCE Z4"2.816 MASTERFILE , 3 1 ry d oZ 3T a 9 �- ZO 72, RECORD INPORMI1TIgN PIIfK,. .