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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existina Facilitv %New EH Proqram and New Facil Facilitv ID Proqram Record ID �ECEENT vet) EB 092023 ENVIR p U/N COUNTY Facility Address o pw� — V� � ALjHDEP ENT ENT Please check theappropriate descri tion and specifysize, number of units and pertinent information. ART41 FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity. Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑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: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ El Hazardous Waste Generator (2200)----------> -Tons Generated Per Year 1:1 Tiered Permitting Facility -------> El CA (2232) El CE (2233, 2234, 2235, 2237) El Aboveground Storage Tank Facility (AST) (2800) Number of ASTs El Underground Storage Tank Program (UST) (2300) Use UST A and B forms El Other CUPA Program Program 3 Facility ❑ PBR (2231) ❑PBR HHW (2236) 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 ❑ NPLISEP Cleanup Site ❑ UIC Site El Abandoned HW Site ❑ non-NPL/SEP Cleanup Site 1:1RWQCB Cleanup Site El Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility 11 Pool El Spa El Out of Service Pool/Spa El Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds El Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) El Body Art Practitioner Reg (4110) 11 Mechanical DSPS Notification (4115) Body Art Facility -Single Use (4120) ❑ Body Art Facility -Sterilization (4121) El Body Art Temp Event Co-ord (4130) El Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration # License # Capacity Vehicle # El Pumper Yard El Package Treatment Plant ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) El Landfill El Transfer Station 1:1Ag/Cannery Waste Site 11Sludge/Ash Site El Waste Tire Facility El Compost Facility ElProcess/Recycle Facility El CIA Landfill Site ❑ Refuse Vehicles (# of Units) ❑ Dumpsters > 20 cu yd (# of Units) ElFarm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) El Primary Care El Acute Care El Skilled Nursing El Large Generator El Small Generator El Limited Hauler El Transfer Station El Veterinary Clinic 11 Common Storage Facility 1:12 - 10 1:111 - 60 El> 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form E ERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON 6 5 1 ' Day Ph hhh PROGRAM ELEMENT Al I,' ID ki FEE 1:1Surchar a FEE El Other FEE INSPECTOR # 9 $ 3 G PERMIT VALID � /q 2Q to 3d 2 11 Food Handler ❑ /Check # AMOUNT PAID(;Co•� Date 23 INVOICE # LJ C VJREVIEWED BY ACCOUNTING OFFICE Date `� y 48- -034 L G�,� MASTERFILE RECO D INFORMATION PINK 1/23/13 Q J