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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility ❑ New EH Pro 0ram and New Facili Facili iD LILL:711tt Program Record ID QQ�v�3 Facility Address hC1LID EfAClFl j T-( 14 (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: 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: ❑ 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 (22332 2234, 2235, 2237) ❑ PBR (2231 ) ❑ PER HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use USTA and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ Hotel/Motel ------Number of Units ❑ Jall or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housina&abor Cama Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remedlation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds ` ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) li 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 Vehicle Registration # License # CapacityTiarw ❑ Pumper Yard [3Package Treatment Plant ❑ Chemical Toilets ----Number of UnPSA SOLID WASTE PROGRAM (4400) K ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑[3ElSludds�iit022 ❑ Waste Tire Facility Compost Facility ❑ Process/Recycle Facility CIA s, f ❑ Refuse Vehicles 0 of Units) ❑ Dumpsters > 20 cu yd (u of units) ❑ FuR/ft5bialiseawslte MEDICAL WASTE PROGRAM (4500) ENVIRONMENTAELLttdd El Primary Care 1:1 Acute Care El Skilled Nursing ❑ Large Generator ❑ Small Generat"TC WdTHauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 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 P OGRAM CONTACT PERSON NI�� N Uts(P Day Ph 1p rJ�JrJ Night Ph PROGRAM ELEMENT N ( 10 FEE a ❑ Sur/ch rge F ❑ Other FEE INSPECTOR # 9 PERMITVALID u Z Z to L3� )moo 2 Ze ❑ Food Handler ❑ Check # -�AMOUNTPAID Date 'ti Pt Z, Z, INVOICE # J Z> 9' ❑ Cash REVIEWED BY �y ACCOUNTING OFFICE Date q 4&02.334 rn. i 2� J MASTERFILE RE OR INFORMATION PINK 1/23/73