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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID Program Record ID S 1s� Facility Address [ (12-01 iped LAJ+i4p5330 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yrs❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units [],Retail Market---Square footage ❑ w/Meat Market only ❑ Multiple Departments 11 Prepackaged Goods Only obile Food Vehicle-Make Vehicle Typ tet,- ---_ Color_3f�-a�- \\ Registration# License# Vt 4'�O VX Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to — 1:1 Ice Plant 11Produce Stand ElSpecial 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 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 Application Form PAYI43Ic1C�l1 1111 ^ SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) eRAYHIC Environmental Assessment ❑ UST-CAP Site Local HW Cleanup Site ❑ NPL/SEP Cleanup Sit C'&D ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality RQp edgia ion Site RECREATIONAL HEALTH PROGRAM(3600) ^� I 1 7 9 Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ %58 t l' g&eY VECTOR CONTROL PROGRAM(4000) ENVIRONMENTAL ❑ Poultry Farm------Maximum number of birds ❑*eWjAj DEPARTMENT TATTOO,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 ❑ 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(#ofunits) ❑ Dumpsters>20 cu yd(#of Units) ❑ Farm/Ranch 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 112-10 ❑ 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 F CONTACTPERSON 1104 M14 Day Ph may- SSL-.�7.S.i6 NightPh;+ZOG/ -Jstp�3sf,� PROGRAM ELEMENT FEE ❑ Surch ge F 11 Other FEE INSPECTOR# � PERMIT VALID !( t0 Z 31 7� '2, ❑ Food Handler ❑ heck# AMOUNT PAID a 3 T^ Datq � �D Z7J INVOICE# �- Cash REVIEWED BY ACCOUNTING OFFICE Date Vj2 ,,8-(T2-034 MASTERFILE RECOR15 INFORMATION PINK 1/33113