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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />LMASTERFILE RECORD INFORMATION FORM <br />❑ New EH Prooram at Existing Facilitv ❑New EH Prooram and New Facility <br />Facility ID W;C7j / I Program Record ID rKO,2L16foZ <br />Facility Address 317 S. C41 l l ► I n �� 1V j526 -Z- <br />(Please check the appropriate description and specify size, 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 Number of Units <br />1:1 tail Market --Square footage —11 w/Meat Market only 11Multiple Departments ElPrepackaged Goods Only <br />l�,liNlobile Food Vehicle—Make UJZV Vehicle Type (A')"1) Color WI%4t& <br />Registration # License #�, Sticker#� <br />[I Mobile Food Prep Unit-- Make Vehicle Type `1 1i1, H (I1y0-5 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 <br />❑ Hazardous Waste Generator (2200) ---------- >-Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use USTA and B forms <br />❑ Other CUPA Program <br />❑ Program 3 Facility <br />❑ PBR (2231) ❑ PBR HHW (2236) <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel----Number of Units ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/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-NPLISEP 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 <br />❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm ----Maximum number of birds <br />❑ Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility <br />-Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Coord (4130) ❑ Body Art -Temp <br />Event pQgpjI FFacci,l'itt T(4131) <br />LIQUID WASTE PROGRAM (4200) <br />pFF'''�/q���' <br />❑ Pumper Vehicle Registration # License # Capacity <br />�rrE G _ <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Unitsr <br />SOLID WASTE PROGRAM (4400) <br />A( <br />f�,t <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑5bd a Ash Site <br />❑ Ctlt`1>I'A UNTY <br />❑ Refuse Vehicles (#ofunus) ❑ Dumpsters> 20 cu yd (#of units) <br />❑waftYAFR4 T 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 112 - 10 011-60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT <br />�. CVILKUL UT IYU I IYIGA I IUN AUK IHib fY1 11-11 T AKU1VKrMWVMMIYI <br />J VT U ,tZtS _ . Day Ph 11VM-T17—WWII Night Ph <br />PROGRAM ELEE���MEN,rT I (U 5-6 FEE <br />INSPECTOR# rad. PERMIT VAL <br />❑ Check #I� AMOUNT PAIL <br />� ❑ Sufch e F El Other FEE <br />u LZ to L � 2 2❑ Food Handier <br />Date I2.1 ),V LL�INVOICE# 31eg, <br />, <br />IJ Cash REVIEWED BY ACCOUNTING OFFICE �- Date $��S�ZZ <br />4123113 4 A4 1 1 / e1 2, t/� � S MASTERFILE RE OR INFORMATION PINK <br />1123113 1/Tj �j <br />