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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Pro ram at Existing Facility ❑blew EH Program and New Facilit Facilitv ID FA 6-/j.17+5 Program Record ID 10549I12- Facility Address hU -S, ( i1` Vi%: ) i I VG S -'f— (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 ❑ Dry storage 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 # Sticker # ❑ Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License #3-- Sticker # �] O ❑ 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 COPA ❑ 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 USTA and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ HotellMotel ----Number of Units ❑ Jail or Exempt Institution ---Number of Units Employee Housing (2700) Use Employee Housina/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) ❑ 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) r�1iNr ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludg 11Waste Tire Facility ❑Compost Facility ❑Process/Recycle Facility El CIA LaRIVE® ndfill Site ❑ Refuse Vehicles (#of units) ❑ Dumpsters> 20 cu yd I# of Units) ❑ Farm/" glefar>4yp,$ite MEDICAL WASTE PROGRAM (4500) ��tt11LLLL ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generato%ldA�lf�Jt2 LeNTy ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 - 60 H MEN PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02.003 Blue Application Form RTMENT 1G EMERGENCY NOTIFICATION FORTHts FACILITY AND/OR PROGRAM * CONTACT PERSON 11 'Q.\� Day Ph O (;; ht Ph PROGRAMELEMENT L^ S FEE ❑ Sur�che e FEE 11 Other FEE INSPECTOR # C! 6 1 PERMIT VALID 141,7442v2-2-' toll.[ N ❑ Food Handler ❑ heck # AMOUNT PAID pC 3� Date u Z/ �%� INVOICE # Cash REVIEWEDBV ACCOUNTING OFFICE Date 8-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13 .1' g' - k