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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facilit Facilitv ID 7�j zZ) tLiNew EH ram Record ID am and New Facil REQ MFT E/ VE® AUG 18 207 Facility Address SAN,/p ENV/ pQ0/N Cp (Please check the appropriate description and specify size, number of units and pertinent information) NCALTN DEpAENM N7')/ FOOD PROGRAM (1600) RT ❑ Restaurant Seating Capacity. Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparatiun ❑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 ❑ 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 (22330 2234,2235; 2237) ❑ PBR (2231) ❑ PER 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 ocal HW Cleanup Site ❑ NPLJSEP Cleanup Site ❑ 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 PoollSpa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm ------Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg Ili 110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) 120"OoBody 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 # License # ❑ Package Treatment Plant Capacity Vehicle ❑ Pumper Yard # ❑ Chemical To[lets --Number of Units SOLID yJASTE PROGRAM (4400) ❑ Landfill ❑Transfer Station 11 AglCannery Waste Site 11SludgelAsh Site ❑ Waste Tire Facility ❑ Compost Facility ❑ ProcesslReeycle Facility ElCIA Landfill Site ❑ Refuse Vehicles t# of Units) ElDumpsters > 20 cu yd (a of untiq ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ElAcute Care ElSkilled Nursing ❑ Large Generator C1Small Generator 13Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility El2 - 10 ❑ 11 60 13> 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EP,1Ft F G ENCY NOTIFICATION FOR THIS FACILITY ANnICiR PROGR CONTACT PERSON PROGRAM ELEMENT +1 !�l C FEE ❑ Surchar a FEE � INSPECTOR # PERMIT VALID ❑ Check# ;! AMOUNT PAID`? ❑ Cash REVIEWED 13Y ae�oz•c�a /y I� Day Ph Zo°! 0-0��6 1____ 3to lle1301, Date 2.2 . vn, Accour,tndr; 0• nl L_ Nighl Ph ❑ Other FEE ❑ Food Handler INVOICE # 3447 Date E12lP/ Wt) itRiIIF i2LCUl,DAT OP104