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SAN JOAQUIN COUNTff NVIRONMENTAL HEALTH DEP/WMENT <br /> MASTERF E RECORD INFORMATION FORM PAY,Ve <br /> o New EH Program at Existing Facility ONew EH Program and New Facility �:�,Ot'Afr <br /> c� <br /> Facility ID Gam,` Program Record ID 2D&4gZ 3 RAR C <br /> Oy Dy <br /> Facility Address r`r;1� Lur_e�rr kve 'SVi koOi . Q A . gaZ3 y E /P U/N <br /> NVj <br /> (Please check the <br /> appropriate description and specify size, number of units and pertinent information.) eAL7./yi4 <br /> D sC f o 1N <br /> FOODPROGRAM(1600) <br /> o Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes oo 0 <br /> o Commissary o Dry storage only o with Food Preparation oVending Machines-Number of Units <br /> o Retail Market----Square footage o w/Meat Market only o Multiple Departments o Prepackaged Goods Only <br /> o Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> o Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> o Temporary Food Facility---Dates of operation from to o Ice Plant o Produce Stand <br /> o Special Event---Dates of operation from to o CFO o A o B <br /> DAIRY PROGRAM(2000) <br /> o Grade A Dairy o Grade B Dairy o Milk Dispenser--Number of Containers in Multi-Head Unit <br /> COPA <br /> o Hazardous Materials Business Plan(1900) Number of chemicals: <br /> o CaIARP Program o Program 1 Facility o Program 2 Facility o Program 3 Facility <br /> o Hazardous Waste Generator(2200)---------->--Tons Generated Per Year <br /> o Tiered Permitting Facility-----> o CA(2232) o CE(2233, 2234,2235,2237) o PBR(2231) o PBR HHW(2236) <br /> o Aboveground Storage Tank Facility(AST)(2800) Number of ASTs <br /> o Underground Storage Tank Program(UST)(2300) Use UST A and B forms <br /> o Other CUPA Program <br /> HOUSING PROGRAM(2400) <br /> o Hotel/Motel-------Number of Units o Jail or Exempt Institution----Number of Units <br /> Employee Housing (2700) Use Employee HousinglLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> o Environmental Assessment o UST-CAP Site o Local HW Cleanup Site o NPUSEP Cleanup Site o UIC Site <br /> o Abandoned HW Site o non-NPUSEP Cleanup Site 0 RWQCB Cleanup Site o Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility 0 Pool o Spa o Out of Service Pool/Spa a Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> o Poultry Farm------Maximum number of birds o Kennel <br /> 'jl�ATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> o Body Art Practitioner Reg(4110) o Mechanical DSPS Notification(4115) 0 Body Art Facility-Single Use(4120) <br /> o Body Art Facility-Sterilization (4121) o Body Art Temp Event Co-ord(4130) o Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> o Pumper Vehicle-Registration# License# Capacity Vehicle# <br /> o Pumper Yard o Package Treatment Plant o Chemical Toilets----Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> 0 Landfill o Transfer Station o Ag/Cannery Waste Site o Sludge/Ash Site <br /> o Waste Tire Facility o Compost Facility o Process/Recycle Facility o CIA Landfill Site <br /> o Refuse Vehicles t#of Units) 0 Dumpsters>20 cu yd(#of Units) o Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> o Primary Care o Acute Care o Skilled Nursing o Large Generator o Small Generator o Limited Hauler <br /> o Transfer Station o Veterinary Clinic o Common Storage Facility o 2- 10 o l l -60 o >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph 1A)03-'L609'0 <br /> PROGRAM ELEMENT Aft ttrFEE H(,- 6 0 Surcharge FEE 0 Other FEE <br /> INSPECTOR# PERMIT VALID ,3 to 30 o Food Handler <br /> 48-02-034 ''ro V MASTERFILE RECORD INFORMATION PINK <br /> 1/23/13 <br />