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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT i MASTERFILE RECORD INFORMATION FORM L7 New EH Proaram at Existina Facilitv I71NAW FH Prnrirnm anti Ncvut Pnrili#v Facility ID "Oi > 2-7 ) 15 Program Record ID-W)7'7L763.2 11 Facility Address 1 h IN Ynj VA (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 Multi -Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Hazardous Waste Generator (2200) ---------- > -Tons Generated Per Year ❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program ❑ Program 3 Facility ❑ PBR (2231) ❑ PBR HHW (2236) 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 Farm -------Maximum number of birds TA OO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) d Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration # ❑ Pumper Yard License # ❑ Package Treatment Plant ❑ Kennel ❑ Body Art Facility -Single UsPAYMENT ❑ Body Art -Temp Event Mob RfEt 0 Capacity VehiclAPR-4—"22 ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) SAN JOAQUIN COUNTY ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludg��NMENTAL EPARTMENT El Waste Tire Facility El Compost Facility 11Process/Recycle Facility ❑ CIA Lan 1 1 e ❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd (# of 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 EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON 8 n \e Day Ph ?I[ Night Ph PROGRAM ELEMENT Pill() FEE l5 ❑ Surch ge FE ❑ Other FEE INSPECTOR# qg,, r PERMIT VALID % Zi' t0[1Food Handler ElC eck # AMOUNT PAID Date INVOICE # �2S Cash REVIEWED BY AccouNTING OFFICE Date '(8-162-034 MASTERFILE RE ORD INFORMATION PINK 1123/13