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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility ❑ New EH Program and New Facility Facility ID Program Record ID Facility AddressNYOGI q4-- (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 (2233, 2234, 2235, 2237) ❑ PER (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 ❑ 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 ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation 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 w------Maximum number of birds ❑ Kennel TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) 'Q 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 # Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----NumberPNCT SOLID WASTE PROGRAM (4400) REIV}.P 11 Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site CJ+� ud&Sa Asn Ite ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility 2,wk 9aflid2622te ❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd (# of units) Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) SAN JOAQUIN COUNTY IR El Primary Care ❑ Acute Care 11 Skilled Nursing L1 Large Generator El Small G L r�ENTAEMHauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 011 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 4642403 Blue Application Form EMER ENCYNOTIFICATION FOR THIS FACILITYAND/OR PROGRAM CONTACT PERSON SU r I V Day Ph J Ip ?D�t ` 2 ht Ph PROGRAM ELEMENT HIiU FEE ISL 11Sur h ge F 11Other FEE INSPECTOR #� � q 1�3 PERMIT VALID b L to )i 11 Food Handler 11 / Check # t4�tw AMOUNT PAID 52 — Date 3v ZD 2, INVOICE # ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 I L / � � / _L MASTERFILE RECORD INFORMATION PINK 1/23/13 �l { (o'(V