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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Pro ram at Existing Facility ❑New EH Program and New Facility Facilit ID D b 2S S Program Record ID 20,S-g6-jS Facility Address S-�yci( n CA OKJv"1 (Please check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating CapacitySquare 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 DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ 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-----> OCA(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 CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution----Number of Units Employee Housing(2700) Use Employee Housina/Labor Camp Anplication Form SITE MITIGATION(2900) UNDERGROUND INJECTION GONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ U1C 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) ❑ Kennel ❑ Poultry Farm------Maximum number of birds TA 00 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# [I Pumper Yard 11 Package Treatment Plant ❑ Chemical Toilets--Number of Units SOLID WASTE PROGRAM(4400) ❑ Slud a/Ash Site El Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site 9 ❑ CIA Landfill Site ❑ Waste Tire Facility [:] Compost Facility ❑ Process/Recycle Facility ❑ Farm/Ranch Cleanup Site ❑ Refuse Vehicles(#of units) ElDumpsters>20 cu yd(#of units) MEDICAL WASTE PROGRAM(4500) El Primary Care ❑ Acute Care 11 Skilled Nursing ❑ Large Generator ❑ Small Generator 11 Limited Hauler ❑ Transfer Station 11Veterinary Clinic [ICommon Storage Facility ❑ 2-10 011 -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 t ( ar` Day Ph� tT�'�s�i- L6Night Ph EPROGRAmEMENT �I I FEE 9 __ ❑ Surcha aFE ❑ Other FEE 9$y_ PERMITVALID to 3b y� ❑ Food Handier � AMOUNT PAID /��•6D Date b INVOICE#REVIEWED BY ACCOUNTING OFFICE Date Q MASTERFILE RE OR INFORMATION PINK 034 1/231/3 10307„55V 1/2311