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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM Lei Fd�v ?1 P+^_g! a: :� Exis'bN 7Facility Facility I'DLfi«p -L7 L� l Facility Address 17 F ►lir, 5+ ❑Herr EH Program and Now F: am Record ID I - (Please check the appropriate descriptlon and specify size, number of u6M FOOD PROGRAM (1600) ❑ Restaurant Seating Capacity Square Footage ❑ Commissary ❑ Dry storage only -❑ with Food Preparation ❑ Retail Market ---Square footage ❑ wWeat lltarket 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 ❑ Special Event—Dates of operation from to — PA YM 1 06 Yjut Oq E QUI and pertinent information.) �q Ty -+_PARTIAL r� 1V7EjVr Food Handlers Course required: YES ❑ No ❑ .❑Vending Machines Number of Units ❑ Multiple Departments ❑ Prepackaged Goods Only Color Sticker # I Color _ Sticker # ❑ Ice Plant 13CFO ❑A❑B Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Glade B Dairy ❑ Wilk 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 Generated Per Year ❑ Tiered .Permitting Facility -> ❑ CA (2232) ❑ CE (=, 2234, 2235, 2237) ❑ PBR (2231) ❑ PBR HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2600) Number of ASTs ❑ Underground Storage Tank Program (UST) i23t70) 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 Housing1t. bor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ ErrvironnTe +tali Asseswmnt 1❑ UST -QA Sift_., ❑; r ocat hW CX=W;.S te; ❑. NPLtSEP CfearnW Sire; Q tiltc site ❑ Abarxioned HW Site Q narf-NPIJSEP Ckwmp Sit 0 Rte$ CSP 13 Water Qua4ft Riermd4alt4orx Sine- - 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 Farm -------Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) 2Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) E1 BDdy-Art'Facitity'Sterlilzation-(4121) DBodyArt Teerp: r►tr;oa isnd (4130) JD'$ody;1*=T&�yp�t LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Regmtration # ❑ Pumper Yard tPaa ."ILY (4131) License # caPaty Vehicle # ElPackage Treatment Plant ❑ Chemical Toilets —Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Waste Tire Facility ❑ Compost Facility ❑ Refuse Vehicles is or units) MEDICAL WASTE PROGIRM, (4.50[1), ❑ Primary Care ❑ Acute Care ❑ Transfer Station ❑ Veterinary Clint ❑ AgiCannery Waste Site ❑ Process/Recycle Facility ❑ Dumpsters > 20 cu yd. (# of units) 13Sludge/Ash Site 13 CIA Landfill Site 12Farm/Ranch Cleanup Site 13Skimed Nursing 13 Large C E3Smag G�L. itcw Q auk Clinic ❑ Common Storage Facility ❑ 2 -10 ❑ 11 -An ❑ > gp generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Aoplicatiort Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON ,�Z` ey�hct n; 1? 14CI Day Ph 9z5 - Ak- X3(Y Night Ph WZS -214, S%W PROGRAM ELEMENT I tr FEE 2 ❑ Surcharge FEE ❑ Other FEE INSPECTOR ;1r 9 3 �lT V,raM 7/ 2 to /3 2 13 i�+ood Hmldlter ❑ check # ! < AgoVNT PAID r / Ga. 2 - C. ❑ Cash 111f1iDICE # I�EyuivED BY ACCOUNTING OFFICE DU�aty,� 48-02-034 dLG / :.. ,�..•..: 1/23/13 � Cr) i 9r Mdfi 0) 7c1 +j2- 61 MASTERFILE RECORD INFORMATION PINK