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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM New . —1 v 'I. Nu--!) Program Record ID -( L Facility Address 'Z� S. ht1 ?eve �()2U CA to (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 ❑ 'bTCommissary tff Dry storage only with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market ---Square footage ❑ W/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle --Make Vehicle Type Color Registration # License # Sticker# ❑ Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # ❑ Temporary Food Facility —Dates of operation from _ Sticker # _ to ❑ Special Event --Dates of operation from to ❑ Ice Plant []CFO ❑ A ❑ B DAIRY PROGRAM (2000) Produce Stand ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit _ CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP 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 USTA 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 ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality I AWENTSite RECREATIONAL HEALTH PROGRAM (3600) RECEIVED Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ NA a BaThi Axea VECTOR CONTROL PROGRAM (4000) LL :JJ LLUU 22 ❑ Poultry Farm --Maximum number of birds ❑ K(l; WUINcouNrr ViHONMEMAt TATTOO BODYPIERCING PERMANENT COSMETIC PROGRAM (4100) HEALTH DEPART101 M, ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration # License # Capacity Vehicle # ❑ Pumper Yard _ ❑ Package Treatment Plant ❑ Chemical Toilets --Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (#of Units) ❑ Dumpsters > 20 cu yd (# of Units) ❑ FarmlRanch 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 ERGEN Y OTIFICATION FOR THIS FACILITY AND/OR PROGRA CONTACT PERSON �a�U C 0'ay Ph 03- (Ooh t;t �OROGRAM ELEMENT D FEE 23 ❑ Surcha e F E ❑ Other FEE JSPECTOR # PERMIT VALID t0 13 Food Handler I Crack# 16:� AMOUNT PAID �7� Date 711 --INVOICE# Cash . REVIEWED BY ACCOUNTING OFFICE Date �� 2 1113 �f' (� $ p.3 -JAZ-L M STERFILER DINFORMATION PINK 1113 `b