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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ,QNew EH Program and New Facility Record ID Facility Address -7250 CG,1,s V%v 6, � ° r_"�' (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 ❑ R tail Market ---Square footage ❑ w/Meat Market only El Multiple Departments ❑ Prepackaged Goods Only Mobile Food Vehicle --Mak i rVehicle Type—_ir Ct L 3 ,- Color {meq Registration License#92 RC 3 1-) 34 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 COPA ❑ 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 ❑ 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 # ❑ Pumper Yard SOLID WASTE PROGRAM (4400) License # ❑ Package Treatment Plant Capacity Vehicle # ❑ Chemical Toilets —Number of Units ❑ Landfill ❑. Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludg�� ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA L c, NT ❑ Refuse Vehicles (#of Units) 11Dumpsters > 20 cu yd (# of Units) ❑Farm ite MEDICAL WASTE PROGRAM (4500) (`� 9 ❑ Primary Care El Acute Care EI Skilled Nursing 1:1 Large Generator El Small Generator LfiLPrrw9,% 1@2r ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 11 - 60SMENV1RONCOUNTY enerators ENVIRON PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form MENTAL EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM "' DEPARiiAYT CONTACT PERSOr{� Day Ph, Night Ph PROGRAM ELEMENT_ FEE❑ Surcharge FEE 11Other FEE INSPECTOR#-� PERMITVALID 9121172 t0 2 3112.Z ❑ Food Handler ❑ C eck # AMOUNT PAID Date 012e -I I 22 INVOICE # h REVIEWED B1Y j� �nAICCcoUNTING OFFICE Date f jJ 2Z 1/23/1334 ,(�% • Q'l MASTERFILE RECORD FORMATION PINK