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SAN'JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />EH Proaram at <br />Record ID ILPO94$a�1 <br />Facility Address , jjG S `h P-✓ evd-1 \-ko- <br />(Please check the appropriate description and specify size, number of unit <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑ Retail Market—Square footage ❑ w/Meat Market only <br />❑ Mobile Food Vehicle —Make Vehicle Type <br />Registration # License #_ <br />❑ Mobile Food Prep Unit..MakeVehicle Type. <br />Registration # License # _ <br />❑ Temporary Food Facility —Dates of operation from <br />r❑�Specciial Event --Dates of operation from to <br />DAIRY PROGRAM (2000) <br />and pertinent information.) <br />Food Handlers Course required: YES ❑ No ❑ <br />❑Vending Machines Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />to ❑ Ice Plant ❑ Produce Stand <br />11 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 />❑ CalARP 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) ❑ PBR (2231) ❑ PBR HHW (2236) <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 />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-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds ❑ 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 # License # Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets —Number of Units <br />SOLID WASTE PROGRAM (4400) 01 <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ SIN]. <br />❑ Waste Tire Facility 11 Compost Facility ElProcess/Recycle Facility ElCIAOXD�Iftp <br />❑ Refuse Vehicles (4 of units) ElDumpsters > 20 cu yd I# of Units) ElFatrr7 <br />/Ranch�p Site <br />MEDICAL WASTE PROGRAM (4500) V �1 %8 <br />❑ Primary Care El Acute Care 11 Skilled Nursing 1:1 Large Generator ❑ Small GerdK*9b ❑ Limit auler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 1 MI T-W&raors <br />PUBLIC WATER SYSTEM PROGRAM ( 600) Use PINS EHDA 46-0 -003 Blue <br />AND/OR PROGRAM 7h��� <br />EMERGENCYfENTAIL <br />CONTACT PERSON °L Day Ph'C�i , _ ', /Night Ph <br />PROGRAM ELEMENT I ( ; XI"F FEE <br />INSPECTOR# ,�4Z PERMIT VAL <br />❑ ,he/ck#�I 11^^ AMOUNT PAID <br />19CSh/IPJI4 REVIEWEDBY <br />48-02,034 <br />1/23113 I5 I / f Xu <br />❑ Sur <br />22+ to _ <br />Date n <br />ACCOUNTING OFFICE (! <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE# 6 <br />Date /4 /4 21— <br />MASTERFILE RECORD INFORMATION PINK. <br />