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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existing Fa Illity ❑New EH Pro ram and New Facilit <br />Facility ID OD,Z� 1$(v Program Record ID Z±-ZZ33 <br />Facility Address-�30 S (Al `(00 St-. SM`Mn) <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: YES ❑ 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 # License # Sticker # _ <br />❑ Mobile Food Prep Unit— Make Vehicle Type Color <br />Registration # License # Sticker # _ <br />❑ Temporary Food Facility —Dates of operation from to ❑ Ice Plant <br />❑ Special Event --Dates of operation from to ❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />Produce Stand <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 />❑ CalARP 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 forms <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 Housing/Labor 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-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _ ❑ Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm ---Maximum number of birds_ <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />(4100) <br />❑ Kennel <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 />License # <br />❑ Package Treatment Plant <br />Capacity Vehicle # <br />❑ Chemical Toilets ---Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Process/Recycle <br />/Re Waste Site ❑ Sl IV?* <br />❑ Waste Tire Facility 11 Compost Facility ❑Process/Recycle Facility ❑ CI I <br />❑ Refuse Vehicles (# of Units) ❑ Dumpsters > 20 cu yd (# of Units) ❑ F ir,Am{Ranc la Site <br />MEDICAL WASTE PROGRAM (4500) �R' , ,,//�1.��1�^, <br />11 Primary Care 11 Acute Care 11 Skilled Nursing El Large Generator 11 Small Ge'- ❑ L'13I&Vauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 1:12 - 10 ❑ 1 6twjR�4* *generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form THDEP E7., At <br />��rr�^11// r� i�/tEME MGN YFTiFI ATIONFORTHISFACILITYAND/OR PROGRAM �TAf <br />CONTACT PERSONI ' `u` Q 1'1 1�? (�O Day Ph Z5- b3,+Ljj ' 1 Night Ph - U?p II � q <br />PROGRAM ELEMENT <br />FEE ' � V ❑ Surchar e F <br />❑ Other FEE <br />INSPECTOR# —Mi% <br />PERMIT VALI <br />22 t0 1 7� <br />❑ Food Handler <br />heck# A <br />U TPAID <br />a$a.4s Date 3 2 <br />INVOICE# <br />c❑ � � <br />a5 2� REVIEWEDBY <br />ACCOUNTING OFFICE <br />Date S �?? - <br />48-02-034 <br />MASTERFILE RECORD INFORMATION PINK <br />1/23/13 <br />