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, -SAN JOAQUIN COUNTY 'VIRONMENTAL HEALTH DEPA 41ENT <br /> MASTERFILL RECORD INFORMATION FORM <br /> iiiew EH Pro ram atExistin Facili ❑New EH Program and New Facility <br /> Facili ID — LF <br /> Program Record ID .7J <br /> Facility Address �-3 g� S -E- tM: !� {2 (•^^dam-� C47 L f� � b <br /> (Please check the appropriate description and specify size,number of units and pertinent Information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating CapadtySquare Footage Food Handlers Course required: YES ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market---Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility---Dates of operation from to ❑ Ice Plant ❑ Produce Stand <br /> ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dalry Q Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUPA <br /> ❑ Hazardous Materials Business Plan (1900) Numberof chemicals: <br /> ❑ CaIARP Program ❑ Program 1 Facility i.7 Program 2 Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator(2200)^-----> Tons Generated Per Year <br /> ❑ Tiered Permitting Facility > ❑CA(2232) OCE(2233,2234,2235,2237) ❑ PBR (2231) ❑ PBR HHW(2236) <br /> ❑ Aboveground Storage Tank Facility (AST) (2800) NumberofASTs <br /> ❑ Underground Storage Tank Program (UST)(2300)Use USTA and B forms <br /> ❑ Other CUPA Program <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteUM'otel------Number of Units , ❑ Jail or Exempt Institution-----Number of Units <br /> Employee Housing(2700)Use Employee Housin4/Latior CaaIR A,pplicatipn Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP 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 PooUSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm-----Maximum number of birds ❑ Kennel <br /> TATTOO BODYPIERCING 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 Vehicle Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles (#of Unts) ❑ Dum psters>20 cu yd(#of Units) ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 ❑ 11 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHO 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON1 4,( e 1Day Ph b lel'1'4cl—b9 a I Night Ph ow-"t <br /> PROGRAM ELEMENT� FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFiCE Date - <br /> 48-02-034 MASTERFILE RECORD INFORMATION PINK <br />