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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existing Facility []New EH Program and New Facility <br />Facility ID jrA6027327 Program Record ID 2D51f7925 <br />Facility Address Vtef //%/,/(/li N1_1L-kfoL . (/{c1 <br />(Please check the appropriate description and specify aUJ 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 Nu er of Units <br />Retail Market ---Square footage ❑ w/Meat Market only LlMultiple Departments Prepackaged Goods Only <br />Mobile Food Vehicle—Make Vehicle Type'Color <br />Registration # License # 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 />❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200) -------- —>-Tons Generated Per Year <br />❑ Tiered Permitting Facility ------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PBR HHW (2236) <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 />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel----Number of Units ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housinu/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP 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 ❑ 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) pp ��ptt�� <br />11 Body Art Practitioner Reg (4110) 11 Mechanical DSPS Notification (4115) ❑ Body Art FacilitySihAllur;NT <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp EvRE f fgilt y (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # License # Capacity -----A%4@#2022 <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets --Numb% of Units <br />�AN JOA UINUIN COUNTY <br />SOLID WASTE PROGRAM (4400) ENVIRONMEN�A�L <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site I.filRgglAAIt7fJ1@NT <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (#of Units) ❑ Dumpsters > 20 cu yd (sof Units) ❑ FarmlRanch 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 1"I IGGRaf tf � Ytil'1nov..�1So'w Day Ph <br />PROGRAM ELEMENT^ 3 FEE ❑ Surc a e F �1 11 Other FEE <br />INSPECTOR# PERMIT VALID t0 ❑Food Handler <br />❑ Check#Vr <br />AMOUNT AID Date ZINVOICE# <br />❑ Cash REVIEWED BYAA-1ACCOUNTING OFFI Date q11 I�U- <br />48-02-034V./ / / MASTERFILE RECORD INFORMATION PINK <br />1/23/13 mil I `y [ c <br />