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i SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECE, VE� NVI MASTERFILE RECORD INFORMATION FORM ,/ 11 ❑ New EH Pro ram alvE�xlstln /Faclll ❑New PH Pro ram and Now FOG ldt Vl 2 20'2, Facllll ID cam✓ �a Pro ram Record ID a LA SAENJVC/ AQUIN CC Facility Address I In I (A 0� I �_` —�� EALTyD fPMENT°Tk TY (Please check the appropriate description and specify size, number of units and pertinent ) NpROMENr FOOD PROGRAM (1600) YES ❑ ❑ Restaurant: seatingCapacity. Square Footage Fired_ Food Handlers Courser au I ❑ Commissary EI Dry storage only 1:1 with Food Preparation ❑Vending Machines Number oUnlea Goods Only 11 Retail Market----Square footage 11 w/meal Markel only ❑ Multiple Departments ❑ prepackag ❑ Mobile Food VehicleColor --Make Vehicle Type - Registration If License # Sticker it Color -------- ❑ Mobile Food Prep Unit-- Make Vehicle Type ticker # -- Registration # License ri Ice Plant ❑ Produce Stand ❑ Temporary Food Facility --Dates of operation from to H ❑ Special Event---Dales of operatiO Cl A IJ on from to CF DAIRY DAIRY PROGRAM (2000) 13 Grade A Dairy El Grade B Dairy [I 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 -------> ❑ CA (2232) ❑ CE (22334 2234, 2235, 2237) ❑ PER (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 Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment CI UST-CAP Site EI Local HW Cleanup Site ❑ NPLISEP Cleanup Site [2 UIC Site ❑ Abandoned HW Site ❑ non-NPLJSEP 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 TATTOOo BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) Body Art FacllltySingle Use (4120) ❑ Body Art Facility-Sterilization (4121 ) ❑ Body Art Temp Event Co-ord (4130) LJ Body Art•Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper VehlcleRegistralion # License # Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toliets ---Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ SludgelAsh Site ❑ Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 ou yd (# or units) ❑ FarmfRanch 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 ❑ 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 TCICkU0 17a Jic; _ Day Ph 2Dq 210-R 2R 2 Night Ph PROGRAM ELEMENT N1a20 FEE ❑ Surcl}ar 0FE ❑ Other FEE !— INSpECrOR # 36 PERM IT VALID 7 Z 2 � t0 (p 1:1 Food Handier ❑ Check # AMOUNT PAID Date 7 Z INVOICE # S ❑ Cash REVIEWED DV ACCOUNTING OFF ICE Date 7 48-02.034 IJ'ASTERFILECO INFORMATION PINK 7/231/3 6W ,�k 12,92. L0 [ /