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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM EH Prooram at 117 ❑New EH Program and Ne Record ID T�6(CL -%D Facility Address SaXnn ,IK "0,0 CA 11 G(Je Square Footage ve.PC�az�sz ❑ Commissary ❑ Dry storage only S`I`it ❑Vending Machines Number of Units ❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle --Make (Please check the appropriate description and specify size, number of units and FOOD PROGRAM (1600) Sticker # ❑ Mobile Food Prep Unit-- Make 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 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 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 ❑ 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 Emp/ovee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) Generated Per Year Environmental Assessment ❑UST -CAP Site ❑Local HW ❑ 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 Emp/ovee 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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds_ ❑Spa ❑Out of Service PoollSpa ❑Natural Bathing Area ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) ❑B0 Art FacilitySingla Use k ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) 11Pumper Vehicle Registration # License # Capacity Vehic6kky'n yn!j = 'Q'9 ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units Kl ar SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludgel/,I�Si y 2021 11 Tire Facility 1:1 Compost Facility ❑ Process/Recycle Facility 1:1 CIA Landfill Site ❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd (# of Units) ❑ FarmiffinWOW"I)MytNy ENVIRONMENTAL MEDICAL WASTE PROGRAM (4500) HEALTH DE ARTMENT 13 Primary Care 1:1 Acute Care ❑ Skilled Nursing ❑ Large Generator 11 Small Generator 11 Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 11 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02403 Blue Application Form CONTACT PERSON t1 I ay Ph Night Ph PROGRAM ELEMENT Olio FEE ISZ' 1 ❑ Surchar FEE ❑Other FEE INSPECTOR# S3 PER MITVALID 2.( t0 ❑ Food Handler ❑Check# L$0.- AMOUNT PAID Date Z VOICE# 3O ❑ Cash REVIEWED 6Y ACCOUNTING OFFICE Date `>< 48-02-034' I A MASTERFILE RECORDINFORMATION PINK 1123/13 5