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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />at <br />i Facility ID %AOQ 2 /0,25 Program Record ID 4ktT:: �PT7'?'i I <br />Facility Address_ 141-? S'. K -A ION KCl T1jVttXK 11-6 U1 <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 />❑Metail Market ---Square footage ❑ w/Meat Market only ❑ Multiple Departments Prepackaged Goods Only <br />11obile Food Vehicle—Make Vehicle Type Color <br />////// ����`` Registration # License # (i �- _) 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 ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to ❑ 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 ASTs <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 />❑ 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-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm ------- Maximum number of birds ❑ 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 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 />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station <br />❑ Waste Tire Facility ❑ Compost Facility <br />❑ Refuse Vehicles (#of Units) <br />Capacity Vejqn <br />❑ Chemical Toilets —Number of <br />7 <br />RECEIVE <br />❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Process/Recycle Facility ❑ Cl"njfill 022 <br />❑ Dumpsters> 20 cu yd (# of units) ❑ Farm/Ranch ClgglWp Site <br />MEDICAL WASTE PROGRAM (4500) SAN JOAQUIN COUIV t T <br />❑ Primary Care 11 Acute Care ❑Skilled Nursing ❑ELarge Generator Small Gene <br />j;LmAndit"Ter <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM n�+c <br />CONTACT PERSON CaV%) U rJ 'R 0114 pi etj 2X Day Ph 2AM-- 3;LI, %i)aNlht Ph <br />PROGRAM ELEMENT FEE 23 — ❑ Surch rge E 11 Other FEE <br />INSPECTOR# 9 PERMITVALID�1 ( Zo2Z to I 3 ❑ Food Handler <br />❑ Check # Amo NIT PAID o� Date yINVQICE # <br />Cash REVIEWEDBYI NI 1\ i ACCOUNTING OFFICE IG{'iO //j Date 6 2� <br />1123113 <br />