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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />I-acm lu u (jv - Pro ram Record ID W I- D <br />S Z <br />Facility Address <br />I <br />(Please check the appropriate description and specify jLz , number of units <br />and gerdrsent Information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant Seating Capacity_ Square Footage <br />�( <br />Food Handlers Course required, Yes R No 0 <br />D Commissary O Dry storage only with Food Preparation <br />OVending Machines Number of Units <br />0 Retail Market—Square footage D w/Meat Markel only <br />D Multiple Departments D Prepackaged Goods Only <br />0 Mobile Food Vehicle -Make Vehicle Type <br />Color <br />Registration# License# <br />Sticker# <br />0 Mobile Food Prep Unit- Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />0 Temporary Food Facility -Dates of operation from <br />to 0ce Plant 0 Produce Stand <br />D Special Event—Dates of operation from to <br />CFO A 118 <br />DAIRY PROGRAM (2000) <br />0 Grade A Dalry 0 Grade 8 Dairy D Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />0 Hazardous Materials Business Plan (1900) Number of dremicals. <br />0 CaIARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />0 Hazardous Waste Generator (2200) --->-Tons Generated Per Year <br />D Tiered Permitting Facility -----> 0 CA (2232) 0 CE (2233, 2234. 2235, 2237) D PBR (2231) D PSR HHW (2236) <br />0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use USIA and forma <br />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />0 Hotel/Motel--Number of Units D Jail or Exempt Institution ---Number of Units <br />Employan Housing (2700) Use Employee, Housina/Labor Camp Appllcagen Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />D Environmental Assessment 0 UST -CAP Site ❑ Local HW Cleanup Site 0 NPUSEP Cleanup Site ❑ UIC Site <br />0 Abandoned HW Site D non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site D Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa D Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />0 Poultry Fane—Maximum number of birds D Kennel <br />TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />0 Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility -Single Use (4120) <br />0 Body Art FacllityStanllzatlon (412 1) D Body Art Temp Event C"rd (4130) D Body Art -Temp Event Mobile Facility (413 1) <br />LIQUID WASTE PROGRAM (4200) <br />D Pumper VehicleRegisiration# License# Capacity Vehicle# PAYMENT <br />13 Pumper Yard O Package Treatment Plant ❑ Chemical Tollets --- Number of Unite RECEIVED <br />SOLID WASTE PROGRAM (4400) <br />0Landfill 0 Transfer Station 0 AgiCannery Waste Site 0 Sludge/Ash Site JUL 18 2022 <br />0 Waste Tire Facility Cl Compost Facility D Procs"Recycle Facility D CIA Landfill Site <br />0 Refuse Vehicles(* or unit,) D Dumpsters> 20 cu Vol IS aunkq 0 FarmlRanch Cleanup Slw JonomN COUNTY <br />MEDICAL WASTE PROGRAM(4500) ENVIRONMENTAL <br />( ) uCAO" OEPARTMENI <br />0 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator D Limited Hauler <br />0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) USE, PNS EHD 16.02.003 Blue Applitatlon Form <br />CONTACT PERSON n Day Ph�- fightPh—L�j 7 S <br />PROGRAM ELEMIENJ, FEE p 08 rge EE D Other FEE <br />NBPEC # PERMIT VALID : (/ L tO ��f �D Food Ha r. <br />Cheek # AMOUNT PAID f Date � i/p Z INVOICE # <br />ACCOUNTING OFFICE r11Y A Date <br />