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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 Address X42 2Z UJYY)PAiCI' LAAkJ— Sfi06k-t n, (A, R,Zl"� (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 COPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility 1:1 Program El Hazardous Waste Generator (2200) ----- ----->-Tons Generated Per Year ❑ Tiered Permitting Facility -------> ❑ CA (2232) 11 CE (2233, 2234, 2235, 2237) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs 11 Underground Storage Tank Program (UST) (2300) Use UST A and B forms 11 Other CUPA Program 3 Facility El PBR (2231) ❑PBR HHW (2236) 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) TATTOO, BODY PIERCING, 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 -------Maximum number of birds ❑ Kennel PERMANENT COSMETIC PROGRAM (4100) �3,Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registratlon # ❑ Pumper Yard License # ❑ Package Treatment Plant SOLID WASTE PROGRAM (4400) ❑ Landfill 11 Trans Station ❑ Waste Tire Facility ❑ Compost Facility ❑ Refuse Vehicles I# of units) MEDICAL WASTE PROGRAM (4500) ❑ Body Art Facility -Single Use (4120) ❑ Body Art -Temp Event Mobile Facility 4131) Capacity Vehl* tGSWED ❑ Chemical Toilets ----Number of Units 11''CCc��-�� uc ' o I'll ❑ Ag/Cannery Waste Site ❑ ProcesslRecycis Facility ❑ Dumpslers > 20 cu yd (# of Units) ❑ SludgelASh Site ❑ CIA La�,�¢jU(;it16UIME�T'AffL.NT ❑ Farm/Rarit�li �,(�t HEALT ❑ 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 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM -'� CONTACTPERSON nny py e4TXr Day Ph2& i ?)I Night Ph PROGRAMELEMENT FEE IS?- ❑ Sur211charge FEE El Other FE E 871 PERMITVALID 6/10/.2,1b1 t0 /30/z Food Handler heck# AMOUNT PAID / S 7 — Date 0 1 VOICE# Cash REVIEWED BY ACCOUNTING OFFICE ate 48-02-034 MA TERFILE RECORD INFORMATION PINK 1/23/13