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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM at Facility Address 222 �7. RF��v S�, d �� e L (�;�,oH i'�._�5�6� (Please check the appropriate description and specify size, number of units and pefi ent information.) F000 PROGRAM (1600) ❑ Restaurant: SeatingCapacity_ 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_ Registration # License # ❑ Mobile Food Prep Unit --Make Vehicle Type Registration # License # ❑ Temporary Food Facility --Dates of operation from to ❑ Special Event ---Dates of operation from to DAIRY PROGRAM (2000) Sticker Sticker # _ ❑Ice Plant ❑Produce Stand ❑CFO ❑A❑B ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser-Numberof Containers in Multi -Head Unit_ CUPA ❑ Hazardous Materials Business Plan (1900) Numberof chemicals: ❑ CaIARP 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) Numberof ASTs ❑ Underground Storage Tank Program (UST) (2300) Use LISTA and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ Hotel/Motel ------Number of Units ❑Jail or Exempt Institution ----Numberof Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Fonn 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) Numberof 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) � 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 VehicleRegistration # License # Capacity Vehicle ❑ Pumper Yard ❑Package Treatment Plant ❑Chemical Toilets ----Numberof Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑Transfer Station ❑ AglCannery Waste Site ❑Sludge/Ash Site ❑ Waste Tire Facility ❑Compost Facility ❑ ProcesslRecycle Facility ❑CIA Landfill Site ❑ Refuse Vehicles (#orumts( ❑ Dumpsters> 20 cu yd (#orunitsl ❑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 46-02-003 Blue Application Form EMERGE CY TIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph 20)q_��JS-!�/�.;eNight Ph PROGRAM ELEMENT H 1 2 � FEE � ,7 3 ❑ Surch//a ge FE ❑Other FEE INSPECTOR# q$r�il, PERMIT VALID 1-i to w30 ❑Food Handler ❑ Check# AMOUNT PAID . � Date Z 2 INVOICE # �� ❑Cash REVIEWED BY ACCOUNTING OFFICE Date S 6 48-02-034 MASTERFILE REC R INFORMATION PINK 1!23/13