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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility ;'New EH Pro ram and New Facility [ Facility ID r4Fri 2 )1.0 ./ Program Record ID VIZ-0 'V'Ul' Facility Address \9 40--9-",- f`A 0 .rN1.--\\-\.),-4J2 '\_).. J __,I °I 51iS (Please check the appropriate description and specify size number of units and pertinent information) FOOD PROGRAM (1600) '. IX Restaurant Seating Capacity IS Square Footage 1:1MI '. Food Handlers Course required: YES gi No 0 Commissary 0 Dry storage only El with Food Preparation [Wending Machines Number of Units Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 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 0 Ice Plant 0 Produce Stand Special Event—Dates of operation from . to 0 CFO 0 A 0 B I DAIRY PROGRAM (2000) Grade A Dairy 0 Grade B Dairy 1:1 Milk Dispenser -Number of Containers in Multi-Head Unit CUPA Hazardous Materials Business Plan (1900) Number of chemicals CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility Hazardous Waste Generator (2200)-------->-Tons Generated Per Year Tiered Permitting Facility ---> 0 CA (2232) 0 CE (2Z33, 2234, 2235. 2237) 0 PBR (2231) 0 PBR NNW (2236) Aboveground Storne Tank Facility (AST) (2800) Number of ASTs s. Underground Storage Tank Program (UST) (2300) Use UST A and B formg 0 Other CUPA Program ir• HOUSING PROGRAM (2400) Hotel/Motel -----Number of Units 0 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 0 UST-CAP Site 0 Local NW Cleanup Site 0 NPLJSEP Cleanup Site 0 UIC Site Abandoned NW Site 0 non-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility 0 Pool 0 Spa , 0 Out of Service Pool/Spa 0 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) 0 Poultry Farm Maximum number of birds 0 Kennel TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4106) Body Art Practitioner Reg (411(4- 0 Mechanical DSPS Notification.(4115) 0 Body Art Facility-Single Use (4120) Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) Pumper VehicleRegistration # Licensd# ; Capacity Vehicle # Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) Landfill 0 Transfer Station 0 Ag/Cannery Waste Site Waste Tire Facility 0 Compost Facility 0 flocess/Recycle Facility Refuse Vehicles (# 01 unas) 0 Durniosters > 20 Cu yd its of Un.1s) MEDICAL WASTE PROGRAM (4500) Primary Care 0 Acute Care 0 Skilled Nursing CI, Large Generator 0 Small Generator 0 Limited Hauler Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 0 > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-06 Blue Application Form EMERGENCY NOTIFICATION FOR TF-IIS FACILITY AND/OR PROGRAM Day Ph av -9igm Night Ph a--64-g ,.90 q —LIM CONTACT PERSON - () Ctr)--lit'jNItekt PROGRAM ELEMENT \ V32_ FEE %SC) -- 0 Surcharge FEE O Other FEE INwEctoR # PERMIT VALID "2:S to --3-"A - 2 O Food Handler Check # AMOUNT PAID 5 s-D V15 Date NVOICE # Date 5127.2.D.A3 Cash Rrvi[wrulfy Ac( OUNTI G OF ICE 433 1,i U14 41,0 MAS I E. RI It F: RECORD INF OPMA DON PINK Sludge/Ash Site CIA Landfill Site Farm/Ranch Cleanup Site 0 •