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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at ExistingFacility ❑New, EH Program and New Facility Facility ID rA0027214 Program Record ID ?90":;4-7992- aS47992- Facility Address - `'1 V W 11sk T -AZ" CW 1537fo (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: Yrs ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market --Square footage ❑ w/Meat Market only ❑ Multiple Departm nts El Prepackaged Goods Only B Mobile Food Vehicle --Make Vehicle Type 'I��AiIQ� 4 Color Registration # License # 4197_-f X 14S 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) ❑ PER 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 HOusind/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-SinPMA"T ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event�Illob IEVVitiMl4131) LIQUID WASTE PROGRAM (4200) IICCCC�� VV CCLLfJ ❑ Pumper Vehicle Registration # License # CapacityclelA 4nDn ❑ Pumper Yard 1:1Package Treatment Plant ❑ Chemical Toilets —Number of Uni L-YGCr-- SOLID WASTE PROGRAM (4400) SAN JOAQUIN COUNTY ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑E d T, � 'f�,bi ENT ❑ Waste Tire Facility ❑Compost Facility ❑ Process/Recycle Facility 11 an I I rte ❑ Refuse Vehicles (#of units) ❑ Dumpsters > 20 cu yd (# of Units) ❑ Farm/Ranch 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 E GENCY OTIFICATION FORTHIS FACI ITY AND/OR PROGRAM COI (p34 - IO 69CONTACT PERSON Day Ph ( *rNight Ph J PROGRAM ELEMENT It? S3 FEE 4i" -1 ❑ Surcharge FEE ❑ Other FEE INSPECTOR#PERMIT VALIDp/�3r�2 z t0 3 2 11 Food Handler El Check # r dt�- AM T PAID I /.tS q ^ Date 3 �' Z INVOICE # Z El Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 �On /Y ,,L 14 L 7 � [ 2 MASTERFILE RECORD INFORMATION PINK 1/23/13 }\Trl`,