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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM Fa New EH Program at Existing Facility ❑ New EH Program and New Facility / FacID �Q0;? 3 (OL Program Record ID f�(zD4: Lf71 $ (v Facility Addresssr7. I u, J-C6 :UALnn ,,(tZf o T� cifrt `'015� 2 ` � ( Please check the appropriate description and specify size, number of units and pertinent information . ) FOOD PROGRAM ( 1600 ) ❑ 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 MultkHead 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 ) ❑ Hotel/Motel ------Number of Units ❑ 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 ❑ 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 ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000 ) ❑ Poultry Farmm -------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 Vehicle Registration # License # Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400 ) ❑ Landfill ❑ Transfer Station ❑ Ag /Cannery Waste Site ❑ Sludge/Ash Site 11Waste Tire Facility ElCompost Facility ElProcess/Recycle Facility ElCIA Land ite El Refuse Vehicles (# or Units ) 11Dumpsters > 20 cu yd (a of Units ) El Farm/ n Re MEDICAL WASTE PROGRAM (4500 ) / FC ElPrimary Care ElAcute Care 11Skilled Nursing 11Large Generator ElSmall Generator Li it d/%66 El Transfer Station El Veterinary Clinic El Common Storage Facility 112 - 10 1111 60 6j1 cng tors PUBLIC WATER SYSTEM PROGRAM (4600 ) Use PWS EHD 46-02-003 Blue Application Form sAN JO ``042 �] , ,, EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM ly FNV/RONIN COON CONTACT PERSON / 111V Day Ph SC d '3 Z �- "71 f Night Ph rH4 MFNT PROGRAM ELEMENT L) I i FEE ❑ Surch r a FE 11 Other FEE owicivr INSPECTOR # Q �' ,� L PERMIT VALID Z7 ZZ to 31�23 ❑ Food Handler ❑ Check # AMOUNT PAID 40 911 A Date 2 ZZ INVOICE # l rq/cas * tj�l& , � REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 1 /23113