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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Exis�tin Facit — ❑New EH Pr rain and ew Facility — Facility ID o _ Program Rec r ID Facility Address 22 3 `�✓t`2v� - - - (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Sealing 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 - El Ice Plant❑ Produce Stand ElSpecial Event---Dates of operation from to CFO fXA ❑ 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 Forrn 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(413 1) LIQUID WASTE PROGRAM(4200) ❑ Pumper VehicleRegistration# . License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Ch Ica[Toilets----Number of Units SOLID WASTE PROGRAM(4400) ko t� + ✓, �j❑ Landfill ❑ Transfer Station ❑ Agl annery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility O�N❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles in of units) ❑ Dumpsters>20 cu yd(t;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 E GENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSONKL-")jz?- Day Ph_ Night Ph J L/ PROGRAM ELEMENT FEE r I ^� ElSurcharge Fee�`� 11 Other FEE / Iticccrrnct! c,�(/ld►' PronA1T VAI In r 1