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I -- --- - REQ MENT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT EI VED MASTERFILE RECORD INFORMATION FORM JUN , ❑New Eli Program at ExistingFacilityew EH Program and New Facility2423 FacilityID C�,Z-]7 Program Record ID ROS+9 HEEN ORON41 COUNry �[ AL Facility Address e, Q�ck e1��•(�lW ( i l�� f q tf�L DSP ENMENr � �l tt t•�r'f>�"t e i �.� �� A R r (Please check the appropriate description and specify jLx2,number of units and dertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course re ua Ired: YEs❑ No ❑ ❑ Commissary ❑ Dry storage only ❑with Food Preparation []Vending Machines Number of Units ❑ Retail Market----Square footage ❑w/Meat Markel only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle-Make Vehicle Tyre Color Registration# _ License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registmtlon# 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 ❑ 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-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑Water Quality Remedlation Site RECREATIONAL HEALTH PROGRAM(3600) Number cf Pools/Spas at Facility ❑ Poo( ❑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(413 1) 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 ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd(#or 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 ! DayPt>'tZ�S I tom ,t'•�Night Ph PROGRAM ELEMENT_LV.b. FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMITVALI (0-13- to ❑ Food Handler ❑ Check# AMOUNT PAI 2 37 Ud Date INVOICE# 73S- • gs❑ Cash REVIEWED BY ACCOUNTING OFFICE Date /v Z 48-02-034 MASTERFILE RECOREJ INFORMATION PINK 112113 C