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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ,t®��aq Qd�New EH Pro ram at Existin Facility ❑New EH Pro ram an—d7New Faclli Facilit ID l`�IcY><2 f) I(�� Pro ram Record ID l��`1L t g7 � ��eV�® Facility Address �� ,P��lfl� �� SulT� � �' .� SgNJOq d t Z(7�Z (Please check the appropriate description and specify size, number of units and pertinent Information.) y��NVjR��/N COU FOOD PROGRAM (1600) Ty D�pq ENTA N�' ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course reouired: YE��IF� ❑ ❑ 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 Facility Registration # License # Slicker # ❑ Mobile Food Prep Unit --Make Vehicle Type Color MEDICAL WASTE PROGRAM (4500) 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: ❑ 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) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ HotellMotel------Number of Units ❑Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Emnlovee Housing/Labor Camp Apalication 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 PoollSpa ❑Natural Bath(ng Area ❑ 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 Vehicle Registration # ❑ Pumper Yard License # ❑ Package Treatment Plant Capacity Vehicle # ❑ 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 tuoruoits) ❑ Dumpslers> 20 cu yd (#or 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 ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form CONTACT PERSON \r� �>>c � ` �� A:AAa Day Ph '�� '' ��+^ S3 � Nlght Ph PROGRAM ELE pMENT °illi FEE ls� ❑ Surcharg Fee ❑Other FEE INSPECTOR# I�S.J PERMITVALI g �2- t0 � `� ❑Food Handler ,4,(�_ heck # AMOUNT PAI �� Date g � � INVOICE # liJ (:ash REVIEWED BY ACCOUNTING OFFICE / Date � b L2 PINK