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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION F ❑ New EH Pro ram at Existing Facility ew EH Program and New Facility Facilit ID b Pro ram Record ID 2,0 ED Facility Address 50 . W-0,01 42Z . (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 11 With Food Preparation ❑Vending Machines Numberof Units ❑ Retail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle --Make Vehicle Type Color Registration # License # Sticker At ❑ 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 (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 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 ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) ❑ Body Art Facility-Sterilization (4121 ) ❑ Body ArtTemp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility (4131 ) LIQUID WASTE PROGRAM (4200) ❑ Pumper VehicleRegistration # 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 10 of units) ❑ Dumpsters > 20 Cu yd R or units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 - 60 C ators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM Sep �FQ CONTACT PERSON I-Q.L&h rio 0 r Lt !K Day Ph95 'g-�Pj �(�' light PROGRAM ELEMENT A,/ f ,7 O FEE f ❑ Surchar e F E 11dt QQNIN - IN$PECTDR # 983L PERMIT VALID t0 ♦7 ElFOOd H �F T NIY ❑ l heck # AMOUNT PAID , r Date q INVOICE # W Cash REVIEWED BY ACCOUNTING OFFICE Date 1/2//4 48-02-034 MASTERFILE RECORD INFORMATION PINK 1123113