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T7:� oo 2-C) Z% SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM 0 Vv 0 ew EH Program at Existing Facility []New EH Program and New Facility Facility IDO�Z 3 7 q Program Record ID 9AfV'66 �Jk Facility Address J C)� q 53.7 (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 Vehicle Type Color Registration# License# 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-------> 11 CA(2232) CE(2233,2234, 2235,2237) PBR (2231) PER H 2236) ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs /� E. )V ❑ Underground Storage Tank Program (UST)(2300)Use UST A and B forms CF�Nv�T rT 11 Other CUPA Program F HOUSING PROGRAM(2400) l O ❑ Hotel/Motel----Numberof Units El Jail or Exempt Institution----NumberU�niCT n , Employee Housing(2700)Use Employee Housing/LaborCamp Application Form Ngq� '�QUI�NOC-2Q SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) vU ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Siteq�TaYi�? y ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site 11RWQCB Cleanup Site 11 Water Quality RemediN? 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(4 100) ❑ 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 Vehicle Registration# 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 Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ 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 ` 11 R ENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM (1,�'�,(�p.�t 1 I Q1 'YY�CJ✓�Q' 1 �{ CONTACT PERSON /1 Day Ph O Night Ph TJ I 4 1 H PROGRAM ELEMENT - ILI FE ❑ SurchargeFE El Other FEE INSPECTOR# C PERMIT VALID b) t0 D .3 11 Food Handler 11Check# _j64,-- AMOUNT PAI 3Z.O� Date L0'0 ? INVOICE# .> 1:1 Cash REVIEWEDOY ACCOUNTING OFFICE Date �� 7 4113 4 _ /t fy� � MASTERFILE REO INFORMATION PINK 1/23/23/13