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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD <br />Facility Address 5!Iy(i <br />-VB(xnu <br />INA,. <br />�1W(V-wl� <br />(Please <br />check the appropriate description <br />and specify size, number of units <br />and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ <br />Restaurant: Seating Capacity <br />Square Footage <br />Food Handlers Course recuired: YEs ❑ No ❑ <br />❑ <br />Commissary ❑ Dry storage only <br />❑ with Food Preparation <br />❑Vending Machines Number of Units <br />❑ <br />Retail Market ----Square footage <br />❑ w/Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ <br />Mobile Food Vehicle --Make <br />Vehicle Type <br />Color <br />Registration # <br />License # <br />Sticker # <br />❑ <br />Mobile Food Prep Unit-- Make <br />Vehicle Type <br />Color <br />Registration # <br />License # <br />Sticker # <br />❑ <br />Temporary Food Facility —Dates of operation from <br />to ❑ Ice Plant ❑ Produce Stand <br />❑ <br />Special Event ---Dates of operation from <br />to <br />❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program 11 Program 1 Facility 13 Program 2 Facility ❑Program 3 Facility <br />❑ Hazardous Waste Generator (2200) -------- -->-Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑PBR (2231) ❑ PBR HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel ------Number of Units ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _ 11 Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds <br />❑Spa El Out of Service <br />PoollSpa <br />TATTOO, BODY PIERCING PERMANENT COSMETIC PROGRAM <br />Lf'�ody Art Practitioner Reg (4110) ❑ Mechanical DEPS Notification (4115) <br />❑ Body Art Facility -Sterilization (4121) 11Body Art Temp Event Co-ord (4130) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registrationtit License # <br />❑ Pumper Yard <br />❑ Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />11 Landfill ❑Transfer Station ❑ AglCannery <br />El Waste Tire Facility ❑ Compost Facility <br />❑ Refuse Vehicles (#of Units) <br />❑ <br />Natural Bathing Area <br />❑ Kennel <br />❑ <br />❑ Body Art Facil�ii��4120) <br />Body Art-TemRE©t IM[acility (4131) <br />Capacity _T �� *�i��12 <br />❑ Chemical Toilets ----Number of Units <br />SANJOAQUW�RT�— <br />ONMENTAL <br />Waste Site ��gp1L BIfb <br />❑ Process/Recycle Facility H LJ CIA Landfill Site <br />❑ Dumpsters > 20 cu yd (# of units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />1:1 Primary Care El Acute Care 11 Skills Nursing <br />11 Large Generator 11 Small Generator 11 Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 11-60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 4602-003 Blue Application Form <br />CONTACTPERSONT*� Day Ph yak-h'nrQZ3 <br />PROGRAM ELEgMaEN�T, x)11 d FEE � I5 � ❑ SI <br />INSPECTOR# PERMIT VALID 2n ZZ t0 <br />❑ Check# l� AMOUNT PAID <br />11 Cash REVIEWED BY <br />1/23/13 <br />ACCOUNTING OFFICE <br />'(orTlightPh <br />ZL-0 Food Han <br />FEE ❑Other FEE _ <br />3D 7� Handier <br />Z. INVOICE <br />Date h l X/22 <br />