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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Prouram at ID Record ID and New Facility Address \ 5 31 ZY)r ( ` 1 r e e k C5 c < rj tVA , C%' -`t �i S _�.)Lu (Please check the appropriate deseripUon and specify size, number of units and pertlnont Information ) FOOD PROGRAM (1600) PA YAq R �E FD sqN MAR ?3 7022 E!y �gQU,NC NEgLTNp11PgRTO LN11V ❑ Restaurant Sealing Capacdy Square Foolage Food Handlers Course required: Yes ❑ No COPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility 110 Hazardous Waste Generator (2200) —> -Tons Generated Per Year ❑ Tiered Permitting Facility —> ❑ CA (2232) ❑ CE (22330 22340 2235, 2237) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTS ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program Program 3 Faclllty ❑ PBR (2231) ❑PBR HHW (2238) HOUSING PROGRAM (2400) ❑ Hotel/Motel—Number of Units ❑ Jail or Exempt Institution —Number of Units Employee Housing (2700) Use Emplovee Housino/Labor Camp Application Fort SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) 11 Environmental Assessment ❑ UST -CAP Site 1:1 Local HW Cleanup Site ❑ NPLISEP Cleanup Site 11UIC Site El Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site 11 Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility _ 11 Pool ❑ Spa 11 Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Fann—Maximum number of birds 11 Kennel TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ,U Body Art Practitioner Rog (4110) IJMechanical DSPS NoUNcaUon (4115) ,L�,Body Art FacllltySingle Use (4120) ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Coord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper VehiclaRegislralion # License # Capacity Vehicle ❑ Commissary ❑ Dry storage only ❑ vAlh Food Preparation ❑Vending Machines Number of Units ❑ Retail Market—Square footage ❑ w/Meal Markel only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle–Make Vehicle Type Color ❑ Registrabon 0 License # Sticker # ❑ Mobile Food Prep Unit– Make Vehicle Type Color ❑ Registration # License It Sticker It ❑ Temporary Food Faclllty –Dales of operation from to ❑ Ice Plant ❑ Produce Stand ❑ SPCC121 Event—Dales of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Common Storage Facility ❑ 2 - 10 11 11-60 ❑ > 60 generators ❑ Grade A Dairy ❑ Grade B Dalry ❑ Milk Dispenser -Number of Containers in Multi -Head Unit COPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility 110 Hazardous Waste Generator (2200) —> -Tons Generated Per Year ❑ Tiered Permitting Facility —> ❑ CA (2232) ❑ CE (22330 22340 2235, 2237) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTS ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program Program 3 Faclllty ❑ PBR (2231) ❑PBR HHW (2238) HOUSING PROGRAM (2400) ❑ Hotel/Motel—Number of Units ❑ Jail or Exempt Institution —Number of Units Employee Housing (2700) Use Emplovee Housino/Labor Camp Application Fort SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) 11 Environmental Assessment ❑ UST -CAP Site 1:1 Local HW Cleanup Site ❑ NPLISEP Cleanup Site 11UIC Site El Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site 11 Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility _ 11 Pool ❑ Spa 11 Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Fann—Maximum number of birds 11 Kennel TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ,U Body Art Practitioner Rog (4110) IJMechanical DSPS NoUNcaUon (4115) ,L�,Body Art FacllltySingle Use (4120) ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Coord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper VehiclaRegislralion # License # Capacity Vehicle CONTACTPERSOI So�ctGL�t0.- Day PhzO`) y4i—�S7SNightPh�VG� PROGRAM ELEMENT �II1C FEE 1 ❑ Surchar eEE ❑ Other FEE INSPECTOR # �2 3 4r PERMIT VALID � � t0 Cl ❑ Food Handler ❑ Check # I it S� AMOUNT PAI �i Date 3 L INVOICE # .�Co ❑ Cash REVIEME)BY ACCOUNTING OFFICE Date �Z- 1&02 A // �0,^0331MASTERFILE RECORD NI ORMATION PINK 123113 �, 4/� # ❑ 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 is of Units)) 13Dumpsters > 20 cu yd it of Units) ❑ FarmlRanch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator O Small Generator ❑ Limited Hauler ❑ Transfer StaUon 13 Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 11 11-60 ❑ > 60 generators CONTACTPERSOI So�ctGL�t0.- Day PhzO`) y4i—�S7SNightPh�VG� PROGRAM ELEMENT �II1C FEE 1 ❑ Surchar eEE ❑ Other FEE INSPECTOR # �2 3 4r PERMIT VALID � � t0 Cl ❑ Food Handler ❑ Check # I it S� AMOUNT PAI �i Date 3 L INVOICE # .�Co ❑ Cash REVIEME)BY ACCOUNTING OFFICE Date �Z- 1&02 A // �0,^0331MASTERFILE RECORD NI ORMATION PINK 123113 �, 4/�