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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facilit Facility ID F -Apo; 74{2 Program Record ID �CLS4$o1D Facility Address U 2D S ':�rlC r;'i ryW Sk • Loci t CA 61 U (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 ❑ Drystorage 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# A—U- ) 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 -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PBR 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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area ❑ Kennel TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) mp �g 11 Body Art Practitioner Reg (4110) EI Mechanical DSPS Notification (4115) 11 Body Art ph1�Ut�s'e (4120) L1 Body Art Facility -Sterilization (4121) El Body Art Temp Event Co-ord (4130) 1:1 Body Art -}RC 1�%22le Facility (4131) LIQUID WASTE PROGRAM (4200) �'�� p ❑ Pumper VehicleRegistration # License # Capacity u4fdS V # 11❑ Pumper Yard ❑ Package Treatment Plant Chemical Toilets --N er of Units �y SOLID WASTE PROGRAM (4400) SAN �OAQUIMEN ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site EN%,tgfgbTSite ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility HIJa- 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 EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph `aCJcf �Q �(oLjNlight Ph �;>Oef r`1g2� PROGRAM ELEMENT UFEE ❑ Surch giF E 1:1 Other FEE INSPECTOR # � PERMIT VALID It •� -i- L t0 ) le %�� ❑ Food Handler ❑ Check# AmouN7 PAID Date I[ $ 2,V L2-- INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date �� t-(-zy 4&02-034^ / MASTERFILE RECORD INFORMATION PINK !1 1/13/13 i ,/ 3011141]