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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ew EH Pro ram and New Facility Facility ID FA 00 24+ii 9 Program Record ID `'}�L j i)*t�, Z Facility Address 1-,54 a&,S 1, Z-� (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 ❑4ce 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 ❑ 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 Farm------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, El Waste Tire Facility El Compost Facility ElProcess/Recycle Facility ❑ CIA L ❑ Refuse Vehicles(#of Units) 11Dumpsters>20 cu yd(#of Units) ElFarm/Ra ' lite MEDICAL WASTE PROGRAM(4500) All �C� 11 Primary Care El Acute Care El Skilled Nursing 13 Large Generator 11 Small GenerRut�t 12 1 r El Transfer Station El Veterinary Clinic El Common Storage Facility El -10 C111 -69Z qbb0 gene rs PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form HF C/RoNMC O(UN�, EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM HD FP NTAt CONTACT PERSON f<� S �I .� �� f Day Ph I S(o i2� Night Ph �1RTiyENT PROGRAM ELEMENT t0 FEE 1 S l3/•�- ❑ Surcharge FEE ❑ Other FEE INSPECTOR PERMIT VALID to ❑ Food Handler ❑Check# AMOUNT PAID ��p:-- Date �1- 2�1 INVOICE# M Cas ^ REVIEWED BY ACCOUNTING OFFICE (l Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/2113