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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New <br />Facilitv ID -rA60z737b Program Record ID -✓V'05�-7190 1I <br />Facility Address 1301 S. SO(GrA mewi+o s+. Loot <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 />❑ Retail Market—Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />*Mobile Food Vehicle—Make Vehicle Type Color <br />Registration # <br />❑ Mobile Food Prep Unit-- Make <br />Registration # <br />❑ Temporary Food Facility —Dates of operation from <br />❑ Special Event ---Dates of operation from <br />DAIRY PROGRAM (2000) <br />License# LZv.I Sticker# <br />Vehicle Type Calor <br />License # Sticker # <br />to ❑ Ice Plant ❑ Produce Stand <br />to ❑ CFO ❑ A ❑ B <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 />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 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 UST A and B forms <br />❑ Other CUPA Program <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-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper VehicleRegistration # <br />❑ Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />License # <br />❑ Package Treatment Plant <br />Capacity Vehicle # <br />❑ Chemical Toilets --Number of Units <br />❑Landfill 1:1 Transfer Station ❑ Ag/Cannery Waste Site ❑ Slud i*s,ite <br />❑ Waste Tire Facility ❑ Compost Facility <br />El Facility ❑ Cl IIIIq <br />❑ Refuse Vehicles (a or Units) El Dumpsters > 20 cu yd (*of Units)13Fa 71 <br />p Site <br />MEDICAL WASTE PROGRAM (4500) ((�� <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generatd"11TIII uler <br />❑ Transfer Station , ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 11 160yunp > 60 g ators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON ✓ Day PhZq. VN 5 - Lj; 1 Night Ph <br />PROGRAM ELEMENT FEEE;4 <br />� ❑ Surchar. e F E 11 Other FEE <br />INSPECTOR# IUB t' PERMIT VALID 2 �2-J t 11 Food Handier <br />/� <br />❑ heck# AMO NT PAID �. Date INVOICE# J7 IT<--/ <br />h VI REVIEWED BY ACCOUNTING OFFICE - Date <br />4820 -034 .1IrVJI �„r _J MASTERFILE RE�Z2 <br />CORD INFORM <br />ATION PINK <br />1/23/13 WWWIPI"I,-UD <br />`j'�/ '7L�//•�/,�n�/��//����J <br />