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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Proaram at Existina Facil Facility ID EH Proqram and New Facil Record ID Facility Address VN KMXVC &T sTuGKyy1 , Cjc '.F2 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) REPn0fn"rnn+0 MCAUG3o� TNRNMC 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)--------M-> -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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farmm-------Maximum number of birds_ ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area ❑ 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# ❑ Pumper Yard SOLID WASTE PROGRAM (4400) License # ❑ Package Treatment Plant Capacity Vehicle # ❑ Chemical Toilets ----Number of Units ❑ Landfill El Trans Station ❑ Ag/Cannery Waste Site ❑Sludge/Ash Site ❑ Waste Tire Facility El Comp Facility ❑Process/Recycle Facility ❑CIA Landfill Site ❑ 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 �pft I CIVItKIi NGY IVVIIrIGHIIVN hVK IFIIJ rHl+lLl I T ANU/UK F'RVVRHIVI -"CONTACT PERSON Day Ph h U• �Zm I 3=y Night Ph PROGRAM ELEMENT `II2� FEE `L° 3 ❑ Surchaafg FEE ❑ Other FEE INSPECTOR # I p5 PERMIT VALID 91361Z2. t0 `W3G ❑ Food Handler ❑ Check # AMOUNT PAID .d0 Date 913 2Z INVOICE # ❑ Cash REVIEWED BY ACCOUNTING OFFICE j Date U0 0 3r 48-02-034 ��((, NI�i uu�� n 1/23/13 � "1v 1`�lf/�1' 1cj'L� MASTERFILE RECORD/INF PINK