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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH ID ❑New EH Record ID Facility Address 3122 r 01( ll16(I . (A 6i5?1°I (Please check the appropriate description and specify size, number of units and pertinent information.) Sq 3 FOOD PROGRAM (1600) H��en' �2� ❑ Restaurant: Seating Capacity. Square Footage Food Handlers Course reau, & ^�AF' O 'Y ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units IRT q< ❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods my ❑ Mobile Food Vehicle --Make Vehicle Type Color Registration it 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: ❑ 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 (22333 2234, 2235, 2237) ❑ PBR (2231) ❑ PER HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and 8 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 ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility _ ❑Pool ❑Spa VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm ------•Maximum number of birds ❑Out of Service Pool/Spa ❑Natural Bathing Area ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg k4 110) ❑ 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 ----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer 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 (# 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 PROGRAM (4600) Use PWS EHD 40-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSONIZU I Day Phjq26"I)1V1-1&324 Night Ph PROGRAM ELEMENT 00 FEE a()L1Surcharjge F ❑ Other FEE INSPECTOR# PERMIT VALID to �/ Z ElFood Handler ❑ Check# AMOUNT PAID s 400 Date 2% INVOICE# V ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 2 4 4 1 Z�1-2R��2S MASTERFILE RECORD. FORMATION PINK 1/23/13123/13