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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT R A�4 MASTERFILE RECORD INFORMATION FORM ❑New EH Program at Existing Facility ❑New EH Program and New Fad li Q [Facility ID Pro ram Record ID RO SANS ,2020 Facility Address �,�tS I.uC,r[e �+•t � � G lyE"�Ro°u/"Cp (Please check the appropriate description and specify size,number of units and pertinent information.) E9i pN 0 pA;i FOOD PROGRAM(7600) gRT/yENT ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes❑ No 11❑ 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 11 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: ❑CaIARP 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 COPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution----Number of Units Employee Housing(2700)Use EmWoyee Housing /Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site El Local HW Cleanup Site 13NPUSEP Cleanup Site ❑ UIC Site ❑Abandoned HW Site ❑ non-NPUSEP 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 VES TOR CONTROL PROGRAM(4000) [3 Poultry Farm------Maximum number of birds ❑ Kennel TATTO 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 VehicleRegistration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant 13 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 urds) ❑ Dumpsters>20 cu yd(#of units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) 17 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 Night Ph PROGRAM ELEMENT q I I Q FEE 111`1� ❑ Surcharg FEE ❑ Other FEE INSPECTOR# 9 g PERMIT VALID Zb to ❑ Food Handier ❑ Check# -�~- AMOUNT PAID L� - d Date Zb INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 4e-02-o3a RE MASTERFILE OR INFORMATION PINK 1/23/13