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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 rA OD 2&6P7Z Program Record ID IPkv:Z4`7 otfwi Facility Address Yt'/ 9 jkIntl i A -AJ (Please check the appropriate description and specify size, number of unit. FOOD PROGRAM (1600) 11 Restaurant: Seating Capacity. Square Footage El Commissary 1:1 Dry storage only L1 with Food Preparation 11 Retail Market ----Square footage Elw/Meat Market only El and pertinent information.) 952/`7 Food Handlers Course required: YES ❑ No ❑ ❑Vending Machines Number of Units 11Multiple Departments ❑ Prepackaged Goods Only DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑Grade 6 Dairy ❑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 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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds _ ❑Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Mobile Food Vehicle --Make Vehicle Type Color Practitioner Reg k Registration # License # Sticker # ❑ Mobile Food Prep Unit-- Make Vehicle Type Color Art -Temp Event Mobile Facility (4131) 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 6 Dairy ❑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 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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds _ ❑Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle ody Art Practitioner Reg k ❑Mechanical DSPS Notification (4 115) ❑B0 Art Facility -Single Use (4120) ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) Registration # License # ❑ Package Treatment Plant Capacity Vehicle # 11 Pumper Yard ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill El Trans Station ❑ Ag/Cannery Waste Site ❑Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (#of units) ❑ Dumpsters > 20 cu yd I# of units) ❑ Farm/Rpj>,CleacN1nnup Site MEDICAL WASTE PROGRAM (4500) Pilo, El Primary Care El Acute Care El Skilled Nursing El Large Generator 11 Small Generator Q L ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 - 60Ca -�6 0gent PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Applicatiop Form J(J 2 202, EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM SAN.lnA,, CONTACT 121 PROGRAM ELEMENT N I I O FEE � $ ❑ 5❑Other FEE 1 INSPECTOR# 9836 PERMIT VALID rOt^ t0 11Check/I#/y AMOUNT PAID Vs� Date ElCash ANyj REVIEWED DY ACCOUNTING OFFICE Night Ph _ Food Ha?n�d—le/fir INVOICE #.mac-J�J7� Date //l�l� 48-02-034 ^ n n 11„hA UL. I /117- n�i1f �{�}.,�1G MASTERFILE RECORD INFORMATION PINK 1123!13 l•�J� ['� / (J L'" Il V! �/�