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SAN J'OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT FMASTERFILE RECORD INFORMATION FORM 1:1 New EH Pro ram at Existin Facilit O New EH Pro ram and New Facility Facility ID EjITR 2'-� Program Record ID U0 63 FacilityAddress -7?-,CD e, Elt (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 ❑ ❑ Commissary ❑ 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 .iT Vehicle Type I2-A\I � Colo Irt.W Registration# License# 4 Q 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 8 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 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 ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP 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) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Atte ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA LandfillrEiife ❑ Refuse Vehicles(#of Units) ❑ Du mpsters>20 cu yd(#of units) ❑ Farm/Ranch Cleanup Site, MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑A wL'im� ited Hauler El Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 1:111 -60 fll% i generators '- CO1JAf PUBLIC WATER SYSTEM PROGRAM (4EMER EUse Nc�NOTWS Ec�noNooR�HI�FACILITYANApplication DIoRPROGRAM JIOEMcN�T� ry CONTACT PERSON 1Y\ j Day Ph L&_ – (e4'2 Night Ph PROGRAM ELEMENT FEE [IS h ge FEE ❑ Other FEE INSPECTOR# PERMIT VALID - l I 22 t0 12- 1 Z� ❑ Food Handler ❑ heck# AMOUNTPAID 2 Date ZZ INVOICE# 36 ( REVIEWED BY ACCOUNTING OFFICE Date LZ 48-0 -034 � ASTERFILE REC IN RMATION PINK H 1/23/13 futtJt/1fl�jv\ O �06liy ri..�y�(,