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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM V PgyM New EH Program at ExistingFacility❑New EH Program and Now FacilityREcE,�10 FacilityID �(3 Program Record ID �� I •� SEP 08 Facility Address 0 to Q S 1010 Please check the PROGRAM (1 00) appropriate description and specify size, number of units and pertinent information.)HE N I ALTtj PIN CO NTy FOOD ❑ Restaurant: Seating Capacity. Square Footage Food Handlers Course required: YES'8M%711 ❑ 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 Registration # El Mobile Food Prep Unit-- Make Registration # 1:1 Temporary Food Facility --Dates of operation 1:1 Special Event ---Dates of operation from DAIRY PROGRAM (2000) 1:1 Grade A Dairy 13 Grade B Dairy Type Color License If Sticker # Vehicle Type Color License # Sticker # to ❑ Ice Plant 1:1Produce Stand to El CFO ❑A❑B ❑ 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 ❑ Program 3 Facility ❑ Hazardous Waste Generator (2200) ------- --->-Tons Generated Per Year ❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PBR HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A 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 HousinglLabor 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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds_roll ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (41 15) ❑ Body Art Facility -Single use k4 140) ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper VehicleRegistration# ❑ Pumper Yard SOLID WASTE PROGRAM (4400) License # ❑ Package Treatment Plant Capacity Vehicle # ❑ Chemical Toilets ----Number of Units ❑ Landfill El Trans Station ❑ Ag/Cannery Waste Site ❑Sludge/Ash Site ❑ Waste Tire Facility 11 comp Facility ❑Process/Recycle Facility ❑CIA Landfill Site ❑ Refuse Vehicles (#or units) ❑ Dumpslers > 20 cu yd I# of units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11-60 ❑ > 60 generators PUBLIC WATER SYSTEM ROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Folin / EMERGENCY NOTIFICATION FOR THIS FACT LITY AND/OR PROGRAM CONTACT PERSON C (\ Day Ph LGLI.;Lib- '� 2(CNight Ph !!! PROGRAM ELEMENT I /10 FEE �X "' ❑ Surchar �e FEE ❑ Other FEE INSPECTOR# �/i7�i PERMITVALID 22 t0 (0 3. ) ❑ Food Handler ❑Check# Vl.sa— AMOUNT PAID ��i Date `18�b INVOICE# 3 ( � ❑ Cash REVIEWED BY . ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECOR INFORMATION PINK 1/23/13