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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION <br />EH Proaram at Existing Facility, []New EH <br />T:�� oo 2- C) 2Ce) <br />u 0 V ° <br />and New Facility <br />4V-66 / -4 <br />Facility Address S,C =_CiA CJ q 557 <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 <br />Food Handlers Course required: Yes ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑Vending Machines Number of Units <br />❑ Retail Market ---Square footage ❑ w/Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle —Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />❑ Mobile Food Prep Unit-- Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />❑ Temporary Food Facility —Dates of operation from <br />to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event --Dates of operation from to <br />❑ 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 />❑ CaIARP 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 UST A and B forms <br />❑ Other CUPA Program <br />❑ Program 3 Facility <br />❑ PBR (2231) <br />❑ PBR H 2236) <br />�ME <br />c N <br />r <br />HOUSING PROGRAM (2400) �� Ar <br />❑ Hotel/Motel----Number of Units ❑ Jail or Exempt Institution ---- NumberUh)ni�CT n , <br />Employee Housing (2700) Use Employee Housing/LaborCamp Application Form Ngq�'�QUTANOC-2Q <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) vU <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup SiteA�T V <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality RemediaYM Mr <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 Vehicle Registration # <br />❑ Pumper Yard <br />License # <br />❑ Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station <br />❑ Waste Tire Facility ❑ Compost Facility <br />❑ Refuse Vehicles (# of units) <br />MEDICAL WASTE PROGRAM (4500) <br />Capacity Vehicle # <br />❑ Chemical Toilets —Number of Units <br />❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Dumpsters > 20 cu yd (# of Units) ❑ Farm/Ranch Cleanup Site <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />11 R ENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM (1,�'�,(�.�t �� 10- YY�L%✓�c� <br />CONTACT PERSON 1 Day Ph Night Ph cfC)�glq)q() O <br />PROGRAM ELEMENTILI - FE �fP ❑ SurchargeFE El Other FEE <br />INSPECTOR# t�MPERMIT VALID q t0 11 Food Handler <br />11Check# _j.56--- AMOUNT PAI 3Z.'06 Date )d 4L;- INVOICE# S <br />❑ Cash REVIEWEDOY ACCOUNTING OFFICE Date �� 7 <br />4/23113 4 _ /t /y � � MASTERFILE RECO INFORMATION PINK <br />1/23/13 <br />