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• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION EORM ❑ New EH Program at Existing Facilit New EH Program and New Facilit Facility ID / Program Record ID 2 Facility Address E a PWJb Cf5351 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating CapacitySquare Footage Food Handlers Course required: Yes❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units V❑ etall Market----Square footage 11w/Meat Market only ❑ Multiple Departments 11 Prepackaged Goods Only Mobile Food Vehicle--Make Vehicle Type Calor Registration# License# Sticker# ❑ Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event---Dates of operation from to [] CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CalARP 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 UST A 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 Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm------Maximum number of birds ❑ Kennel TATTOO BODY PIERCING.PERMANENT COSMETIC PROGRAM (4100) ❑ 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 VehicleRegistration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets---Number of Units SOLID WASTE PROGRAM(4400) �w ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash$jtA ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfillftl ,,11eNT ❑ Refuse Vehicles p of Units) ❑ Dumpsters>20 cu yd(#of Units) ❑ Farm/Ranch leanu�` ii MEDICAL WASTE PROGRAM(4500) JULUJJjj ❑ Primary Care 11 Acute Care El Skilled Nursing 1:1 Large Generator El Small Generator ❑Avptfad Hau`J02Z ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 011 -60 [�&/td4&'V/obp PUBLIC WATER SYSTEM PROGRAM ( 600)EMEUse PNS EHDAT46-02-00ON FOR 03 Blue Application Form PROGRAM �,.t^ACTH DE'`'M'UHr CONTACT PERSON LA DUW Day Ph 0 Night Ph VV'-IL PROGRAM ELEMENT F ❑ Surchargg FEE ❑ Other FEE I,NSSPP,ECTOR# ��tt PERMIT VALI ZZ to 121-1 vi 22 ❑ Food Handler Iy "&X2k# 1V AMOUNT PAID Ing Date ZZ INVOICE# 7,21 ❑ Cash REVIEWEDBY ACCOUNTING OFFICE 9 Date Vt3 V23113 48,02-034 23 1334 W AT-HO/�nr� MASTERFILE RECORD INFORMATION PINK