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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Proaram at Existina Facilitv []New EH Proaram and New Facility <br />Facility ID FAA -,02'72-S1 Program Record ID r&52.1%$ <br />Facility Address 730 S Cal(Fo rn, o, St Sfioc 4ovL Chi- `?52 <br />PA <br />Rec Emelv <br />ED <br />3 RAN JUL <br />(Please check the appropriate description and specify size, number of units and pertinent information.) d f/ OAQ � s O�Nz <br />FOOD PROGRAM (1600) 7' ,fDE WIV'r �Y <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes �R <br />❑ Commissary ❑ Drystorage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />❑ Retail Market ---Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ M ile Food Vehicle—Make Vehicle Type Color <br />Registration # <br />License #_ <br />Mobile Food Prep Unit-- Make <br />Vehicle Type <br />Registration # <br />License #_ <br />❑ Temporary Food Facility —Dates of operation from <br />❑ Special Event ---Dates of operation from <br />to _ <br />to <br />Sticker # <br />_ Color <br />Sticker # <br />_ ❑ tee Plant ❑ Produce Stand <br />11 CFO ❑A❑B <br />DAIRY PROGRAM (2000) <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 />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility <br />❑ Hazardous Waste Generator (2200)-------> -Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of AST$ <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <br />❑ Program 3 Facility <br />❑ PBR (2231) ❑ PBR HHW (2236) <br />HOUSING PROGRAM (2400) <br />❑ HotellMotel ------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 ❑ NPLISEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP 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 />❑ Kennel <br />TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <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 Coord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # <br />❑ Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />License # <br />❑ Package Treatment Plant <br />Capacity Vehicle # <br />❑ Chemical Toilets ---Number of Units <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (#of units) ❑ Dumpsters> 20 cu yd (#of Units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11-60 . ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02.003 Blue Application Form <br />CONTACT PERSON 0OtJaC?-g Day Ph q,2 9hr7 -S / _ Night P 14J i 0' <br />PROGRAM ELEMENT I FEE () ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR# PERMIT VALID Z2— to ❑ Food Handier <br />1:1 Check # AMOUNT Paf . D� Date INVOICE # d(o p 6� <br />cash REVIEWED BY I it 1 A �JA, ACCOUNTING OFFICE Date <br />1/23/13 <br />