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`SAN, JOAQUIN COUNTY EORONMENTAL HEALTH DEPARTIONT MASTERFILE RECORD INFORMATION FORM ❑ New EH Proaram at Existing Facilitv ❑New EH Program and New Facility II Facilitv IDProgram Record ID 71CQSy'Jv�o II Facility Address W WlXA (Please check the appropriate description and specify size, umber o unit: FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ Mobile Food Vehicle --Make Registration # ❑ Mobile Food Prep Unit-- Make Registration # ❑ Temporary Food Facility --Dates of operation from ❑ Special Event ---Dates of operation from DAIRY PROGRAM (2000) and pertinent information.) Food Handlers Course required: YES ❑ No ❑ ❑Vending Machines Number of Units ❑ Multiple Departments ❑ Prepackaged Goods Only Vehicle Type_ License # Vehicle Type License # _ to Color Sticker # _ Color Sticker # ❑ Ice Plant ❑ 11 CFO ❑A❑B Produce Stand ❑ 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 -------> ❑ 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 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 ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC 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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds _ ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ody 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 Vehicle Registration # ❑ Pumper Yard License # ❑ Package Treatment Plant SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Waste Tire Facility ❑ Compost Facility ❑ Refuse Vehicles (# of units) Capacity Vehicle # ❑ Chemical Toilets ----Number of Units ❑ Ag/Cannery Waste Site ❑ Process/Recycle Facility ❑ Dumpsters > 20 cu yd (# of Units) PAYMENT ❑ Sludge/Ash SitRECEOVED ❑ CIA Landfill Site ❑ Farm/Ranch ClK"VPLFt 2018 MEDICAL WASTE PROGRAM (4500) ❑ Primary Care El Acute Care El Skilled Nursing El Large Generator El Small Generator ❑ Limi PIN COUNTY ❑ Transfer Station ❑ VeterinaryClinic El Storage Facility ❑ 2 - 10 ❑ 11 - 60 ❑ > 6 I NMENTAL g Y Q ill. ARTMENT 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 D Z i2 Night Ph "I—,t� PROGRAM ELEMENT FEE �Z� ❑ Surchar a FEF❑ Other FEE INSPECTOR # bD3� PERMIT VALID R g t0 �'1 ❑ Food Handler q ❑ Check# AMO1UNTTPAID#ISZ Date INVOICE# 11M 3/?57 l Cash REVIEWED BY IN/\ ACCOUNTING OFFICEWl— Date 034 �Q I MASTERFILE RECORD INFORMATION PINK 1123//3 C> rt.