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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility Mew EH Program and New Facility 11 Facility ID Prooram Recci ID I Facility Address Foil r kanr&r roll L.)QU I (Please check the appropriate description and specify size, number of units FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑ Retail Market—Square footage ❑ w/Meat Market only ❑ Mobile Food Vehicle --Make Vehicle Type Registration # License #_ ❑ Mobile Food Prep Unit- Make Vehicle Type _ Registration # License #_ ❑ Temporary Food Facility --Dates of operation from ❑ Special Event --Dates of operation from to DAIRY PROGRAM (2000) and pertinent information.) Food Handlers Course required: YES ❑ No ❑ []Vending Machines Number of Units ❑ Multiple Departments ❑ Prepackaged Goods Only _ Color Sticker # Color Sticker # to�❑ 1 Plant 11 Produce Stand eFO 97A❑B ❑ 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 Housing/Labor 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-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 TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) LIQUID WASTE PROGRAM (4200) ❑ Pumper VehicleRegistration # ❑ Pumper Yard License # ❑ Package Treatment Plant SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Waste Tire Facility ❑ Compost Facility ❑ Refuse Vehicles I# of Units) MEDICAL WASTE PROGRAM (4500) ❑ KennPAYMENT ❑ Body Art Facility -Single UsseeF(d'T20JIVE® ❑ Body Art -Temp Event MolfloFeVI (2621) Capacity VSIWd(VAQUINCOUN7Y ❑ Chemical Toilets ----Number of Unit ENVIRONMENTALT M NT A ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Dumpsters > 20 cu yd I# of Units) ❑ Farm/Ranch Cleanup Site ❑ 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 EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON SkepV%ayle. Qe(rL& Day Ph R73 435-4 Night Ph (-6t26)Li 10 PROGRAM ELEMENT I(D(Rf FEE _ INSPECTOR# PERMIT VALID II F L 1:1Check # AMOUNT PAID IS' ❑ Cash REVIEWED BY ACCOUNTING 4/23113 4 1/23113 gooCp6 yy t, ❑ Surcharg FEE 1:1 Other FEE _ to I 0 ❑ Food Handler Date INVOICE # Date 1 ,- J� 14 /� 1 17 66 Vf .f1 1.12MA,SGTEQRFILPE�R(ECOc{RD INFORMATION PINK