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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at ID ❑New EH Proaram and New ram Record ID Facility Address ZsZs S. Hu4-cA; sLo hI -07f 0Is-74b (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 F Vehicle Type Color Package Treatment Plant ❑ 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) PIERCING PERMANENT L122!, COSMETIC PR OGRAM (4100) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit COPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility 11ElHazardous Waste Generator (2200) ---------- >-Tons Generated Per Year ElTiered Permitting Facility -------> ElCA (2232) El CIE (2233, 2234, 2235, 2237) 13Aboveground Storage Tank Facility (AST) (2800) Number of AST$ ElUnderground Storage Tank Program (UST) (2300) Use UST A and B forms ElOther CUPA Program Program 3 Facility ❑ 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 Housin4/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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds _ ❑Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area ❑ Kennel SOLID WASTE PROGRAM (4400) ❑ Landfill 13 Transfer PIERCING PERMANENT L122!, COSMETIC PR OGRAM (4100) Body Ar�o Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) ❑Body Art Facility -Single Use (4120) ❑ Body Art Facility -Sterilization (4121) ❑ Body An 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 Station ❑ Ag/Cannery Waste Site ❑Sludge/Ash Site ❑ Waste Tire Facility 13 Compost Facility ❑ Process/Recycle Facility ❑ CIA �Li I ❑ Refuse Vehicles (# of units) ❑ Dumpsters> 20 cu yd I# of units) ❑ Farrr Vel I�g I�'Site MEDICAL WASTE PROGRAM (4500) "P6 !,y /'p El Primary Care El Acute Care 1:1 Skilled Nursing El Large Generator 13 Small Generator�,g�t' i It d Haau cr 13 Transfer Station ❑ Veterinary Clinic El Common Storage Facility El - 10 [1 11 - 6 LJ'> 0 gQ*ftors PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form NVIAQU11V CONTACT PERSON e>< kao ENcvERGNonFlcanoNFon DayFPhCIZTYANCn(vifl6$ jNighlPhH TyD� TT'It PROGRAM ELEMENT g110 FEE 'd f ❑ SurC�hnna ge F E El Other FEE INSPECTOR# 923/. PERMIT VALID t0 �Y11 4 1GZ1 ❑ Food Handler Vheck # AMOUNT PAID f5� Date (� INVOICE# as& J REVIEWED BY ACCOUNTING OFFICE 1'l,( / 1 Date 7i/� 9a-01-0:54 V MASTERFILE RECORD INFORMATION PINK 1/23/73