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e SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT R;j yM MASTERFILE RECORD INFORMATION FORM EIH Program and New Facility /'`C��IF'�T El New EH Pro ram at Existin Facility ��p J, rq V�O Program Record ID 2 SSA ?, jlCly ?022 Facility ID Goz-7.37 "I �, oFacilityAddress 11 '� �ii� C Y�� Di� maw Lf Y9(� yF'14/R'-GNa"/ oo NQF ,,INTy (Please check the appropriate description and specify size, number of units and pe nent mformauon.) fi C YES ❑ N %cN FOOD PROGRAM(1600) T ❑ Restaurant: Seating Capacity__ Square Footage Food Handlers Course Number re storage only ❑ with Food Preparation ❑Vending Machines Number of Units ood y ❑ Commissary ❑ Dry 9 y ❑ w/Meat Market only [Multi le Departments❑ PrepaYc]kaged C Y ❑ Retail Market---Square footage 1i-QI Color rJIV —� Vehicle Type O Mobile Food Vehicle--Maker License# y Sticker#— Registration# Vehicle Type Color ❑ Mobile Food Prep Unit--Make License#� Sticker# Registration# ❑ Ice Plant❑ Produce Stand ❑ Temporary Food Facility—Dates of operation from to to ❑ CFO CIAO B ❑ Special Event---Dates of operation from DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CLIPA O 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) [ICE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PER HHW(2236) ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs ❑ Underground Storage Tank Program(UST)(2300) Use UST A and 8 forms L ❑ 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 LJNPL/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) 11 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 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) ❑ FarmlRanch 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- 10 011 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Fortin EMERGENCY O CONTACT PERSON 1`11,\,V1 yl PO'—N ATIOR T �ON FORay THISFACILITY Y AND/OR PR�G7R�AN ght Ph .20Q—SCI-74,03 7 PROGRAM ELEMENT \b33 FEE ) ❑ SurcharkFEE ❑ Other FEE �-7 INSPECTOR# L\n es PERMIT VALID /�Z.�I Z-Z t0 2 Z ❑ Food Handler_❑ Check# �jj AMOUNT PAID c� Date �7 / EM—ASTFORFILE4REC IN CE c5 ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date /6 7 2Z ae-o2 D INFORtrz3n3INFORMATION PINK szs�z�