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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 Facility ID r�'WCO272-1 b Program Record ID 4TD4-777(-) Facility Address 1'!iC> S 0 C CA �-VlPA -�F (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 etail Market ----Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only Mobile Food Vehicle -Make VehicleType Color Registration # License # 1j I I eq e_- 1-3 Sticker #� 11Mobile Food Prep Unit-- Make Registration # 11Temporary Food Facility -Dates of operation from 11Special Event ---Dates of operation from DAIRY PROGRAM (2000) 11Grade A Dairy ❑ Grade B Dairy Vehicle Type Color License # Sticker # to to _ ❑ Ice Plant ❑CFO ❑A❑B Produce Stand ❑ 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 ❑ Hazardous Waste Generator (2200) -------->-Tons Generated Per Year ❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program ❑ Program 3 Facility ❑ PBR (2231) ❑ PBR HHW (2236) HOUSING PROGRAM (2400) ❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housinq/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP 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) ppYMIENT ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facilitz�EMD) 11 Body Art Facility -Sterilization (4121) 11 Body Art Temp Event Co-ord (4130) 11 Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) JUN 0 3 20'22 11Pumper Vehicle Registration # License # Capacity Vehicle # 11 Pumper Yard El Package Treatment Plant El Chemical Toilets--Numb�j—fa UIN C.I_., — ENVIRONIdIEI TAL SOLID WASTE PROGRAM (4400) MTH DEPARTMENT ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site LJ 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 PERSON y Ph NS `/- Night Ph S PROGRAM ELEM/E/N�1T FEE �❑ Surch�fpe FEE, ❑ Other FEE INSPECTOR # 56 L PERMIT VALID a %2 7 to 2-o Z Z 3 Food Handler eck# AMOU^N!Z TPAID - Date 21:2INVOICE#// V❑ Cash REVIEWED BY I'N , `� ACCOUNTING OFFIC / ///�-.'�/7�' Date 6 -712-7-