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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT �pqY MASTERFILE RECORD INFORMATION FORM L� r New EH Program at Existing Facility ❑New EH Program and New Facility CJL��/ Facility ID Db27DRS Program Record ID ApR p, Facility Address 152)1 Zvttt S[b e Eiy6\(% (' yFF L/O Qui ?�?? (Please check the appropriate description and specify size, number of units and pertinent information.) A�TND pAR ME�ry FOOD PROGRAM 1600 /�� 13 Restaurant: Seating Capacity. Square Footage Food Handlers Course required: YES ElNo ❑ ❑ 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 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) ❑ PER (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 Emplovee Housina/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-NPUSEP 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) N/Body Art Practitioner Reg (4110) ❑ 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) ❑ CONTACT PERSON i1�1(\V'E'.V1/ \lllfA(,U,(,1 Day Ph 7 Landfill 1:1 Transfer Station ❑ Ag/Cannery Waste Site ❑Sludge/Ash Site ❑ Waste Tire Facility El co Facility ❑Process/Recycle Facility ❑CIA Landfill Site ❑ Refuse Vehicles R 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 1:12 -10 ❑ 11 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02403 Blue Application Form O Night Ph PROGRAM ELEMENT `III O FEE �f ❑ Surchar a FEE ❑Other FEE INSPECTOR # 9:53 PERMIT VALID ZZ t0 40 Z 11 Food Handler ElCheck # AMOUNT PAID Date 7INVOICE # ElCash REVIEWED BY ACCOUNTING OFFICE Date 2Z 48-02-034 MASTERFILE RECORV INFORMATION PINK 1/23/13 /28 49 73S -7 /84973s7