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SAN JOAQUIN COUNTY E( ONMENTAL HEALTH DEPARTONT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility []New EH Program and New Facility Facility ID D02 Program Record ID ?IZUL4 Facility Address vu,-I e- fit? �cc,-- C44 .. gS-37(� (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# Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B M DAIRY PROGRAM (2000) �Aq yME`�r 13 Grade A Dairy 13 Grade B Dairy El Milk Dispenser-Number of Containers in Multi-Headft CUPA jyV El �U Hazardous Materials Business Plan (1900) Number of chemicals: 9 ?0�8 ElCaIARP Program ElProgram 1 Facility ElProgram 2 Facility ElProgram 3 Facility SAN OAQONC ❑ Hazardous Waste Generator(2200)----------> Tons Generated Per Year "ZZ-1 am;j 0UN7, ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR(2231) ❑ PBR #� 171 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs NT ❑ 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) ❑ 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) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ 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 112- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Fomm EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON (,l1, Day Ph "Cq - Night Ph PROGRAM ELEMENTY/IQ FEE El Surcharge F-E 1:1 Other FEE INSPECTOR# L +Ak7 /J PERMIT VALID .11111119 t0 L2.3 I ❑ Food Handler ❑ Check# I Sots AMOUNT PAID aC/ Date 1 t g INVOICE## 31'710 ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RE� NFORMATION PINK 1/23/13 � � ?1530