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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FPIfM ❑ New EH Program at Existing Facility ew EH Program and New Facilit FacilityID Q Program Record ID FRo /,In Facility Address I Z V ;535 (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❑ 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# — U-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: ❑ 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) ❑ 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 HousinWLabor 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-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 Facility-Single Use(4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body ArtTemp 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) t1?! ❑ Landfill 1:1Transfer Station ElAg/Cannery Waste Site ❑ Slud +♦�"1:1Waste Tire Facility 1:1Compost Facility 1:1Process/Recycle Facility EllCIA La �Qw� El Refuse Vehicles(#of units) 11Dumpsters>20 cu yd(#of Units) 13Farrga cryh Cleatosite MEDICAL WASTE PROGRAM(4500) �'__1K�` 8 ?��n77 ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Genepra��J5q�lited'PI54DIer ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112-10 ❑ 11 --"'^IITH �Ni ators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46.02.003 Blue Application Form DEP,'��Bf.Y EMERGE Y NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM ZVp",• •./ CONTACT PERSON . L Day Ph Night P ) J a G0"�� PROGRAM ELEMENT FEE 44j ^00 ❑ Surchar a EE 11 Other FEE INSPECTOR# O PERMITVALID �Z f—s—' t0 tZ ❑ Food Handler cyp ❑ he c AMOUNT PAID j,�- Date 2 Z2i INVOICE# 3 (060 as �. REVIEWED BY ACCOUNTING OFFICE Date ZY 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13