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Lt JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing F cility LYINeW EH Program and New Facility Facility ID bqbD2�7 )`24 Program Record ID fkDES662— Facility Address _ (Please check the appropriate description and specify size, number f units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs [1 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 ErMobile Food Vehicle—Make rU. - Vehicle TypeyuR'/ j'} Colorrayl ,-- Registration# L/M9MIrb]� NStlR31) /License# Sticker# 40 ❑ 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-------> ❑ CA(2232) ❑ CE(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 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) PiA�Uflllll. ❑ Poultry Farm-------Maximum number of birds f7Jl�lt#rr TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) RECEIVED ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art Facilritty-Sin lg Useyf.4�120) El Body Art Facility-Sterilization (4121) El Body Art Temp Event Co-ord(4130) 13 Body Art-Tempi MoMacility(4131) LIQUID WASTE PROGRAM(4200) SAN JOAQWIN COUNTY 11 Pumper Vehicle Registration# License# Capacity _---- J %"TA ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----NumEpL'ORDffR.ARTMENT 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 Is 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 EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON .N -icrrCa S Day Ph - Y 32-y-i/702 Night Ph PROGRAM ELEMENT FEE ❑ Surch ge FeE ❑ Other FEE INSPECTOR# ,)E— PERMIT VALID LO7-- t0lq=t:, ❑ Food Handler ❑ heck# AMOUNT PAID 3�- — Date '7/ 2LZINVOICE# 7 Cash REVIEWED BY ACCOUNTING OFFICE Date Z� (48"62-034 MASTERFILE RECORD INFORMATION PINK 1/2 1123/1