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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM 7M ❑New EH Prooram and New Facility ID r-rtrXJLL-j SU Program Record ID fes/ b 3 Facility Address 71 %d lest In 4 � t�/ gn(A k a C4 Z/l% (Please check the appropriate description and specify size, number of units andpertinent information.) FOOD PROGRAM (1600) RCE ED DEC Z 12021 S NVIRpNNCOUry7Y HFALTy pE ARTMENT ❑ 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 ElElHazardous Waste Generator (2200) ---------- >-Tons Generated Per Year El Tiered Permitting Facility -------> 11 CA (2232) El CE (2233, 2234, 2235, 2237) 11 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs 11 Underground Storage Tank Program (UST) (2300) Use UST A and B forms EI Other CUPA Program Program 3 Facility ❑ P8R (2231) ❑ P8R HHW (2236) HOUSING PROGRAM (2400) LiHotel/Motel- ---- -Number of Units 1:1N Jail or Exempt Institution ----umber of Units Employee Housing (2700) Use Empioyee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) 11 Environmental Assessment ❑ UST -CAP Site El Local HW Cleanup Site 11 NPL/SEP Cleanup Site ❑ UIC Site 11 Abandoned HW Site El non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site El Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑Pool VECTOR CONTROL PROGRAM (4000) 1:1 Poultry Farm -------Maximum number of birds_ ❑ Spa ❑ Out of Service Pool/Spa ❑Natural Bathing Area 11Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg k4 110) ❑ Mechanical DSPS Notification (4115) IJ Body Art Facility -Single Use (4120) ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) El Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) 11 Pumper Vehicle Registration # License # Capacity Vehicle # 11 Pumper Yard El Package Treatment Plant El Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) 11 Landfill 1:1 Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site El Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility El CIA Landfill Site 11 Refuse Vehicles (#of units) ElDumpsters > 20 cu yd Rof units) ElFarm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) 1:1 Primary Care ❑ Acute Care El Skilled Nursing 11 Large Generator El Small Generator 11 Limited Hauler ❑ Transfer Station El Veterinary Clinic El Common Storage Facility El - 10 1111 -60 CONTACT Day Ph PROGRAM ELEMENT �IIIO FEE alSa ❑SI. INSPEc7oR# T'�9 PERMITVAL IZ 2 i- to cJ ❑ Check # 4e i AMOUNT PAI Z b D Date ❑Cash REVIEWED BY 48-02-034 1/23/73 ACCOUNTING OFFICE 131 ,_SGZh6L Night Ph _ u umer ree 2�— ❑Food Handler INVOICE # 3 Z�0 Date LiL2L MASTERFILE RECORD INFORMATION PINK ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form CONTACT Day Ph PROGRAM ELEMENT �IIIO FEE alSa ❑SI. INSPEc7oR# T'�9 PERMITVAL IZ 2 i- to cJ ❑ Check # 4e i AMOUNT PAI Z b D Date ❑Cash REVIEWED BY 48-02-034 1/23/73 ACCOUNTING OFFICE 131 ,_SGZh6L Night Ph _ u umer ree 2�— ❑Food Handler INVOICE # 3 Z�0 Date LiL2L MASTERFILE RECORD INFORMATION PINK