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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility 07 ew EH Pro ram and NevCFacilitv Facilit ID 3 Program Record ID Facility Address_'11LA Rtsm (A7 man r (�n q,5--3-3o i (Please check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) 9 ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES Nfl"No ❑ t ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market----Square footage ❑ w/Moat Market only ❑ Multiple Departments❑ Prepackaged Goods Only r ❑ Mobile Food Vehicle—Make _ _ Vehicle Type Color I Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ic Plant[I Produce Stand El Special Event---Dates of operation from to CFO IA ❑ 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: 11 1 CaIARP Program E1 Program 1 Facility El Program 2 Facility 11 Program 3 Facility13 € 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 1 ❑Underground Storage Tank Program (UST)(2300)Use USIA and B forms ❑ Other CUPA Program HOUSING PROGRAM(2400) I ❑ 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 r 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) 1 Landfill 11 Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site P ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site e ❑ Refuse Vehicles(#of units) _ ❑ Dumpsters>20 cu yd I#of units) ❑ Farm/Ranch Cleanup Site P 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 Daisy Oc( Ucda Day Ph 510-566-4755 Night Ph PROGRAM ELEMENT 1608 FEE 186 ❑ Surcha ge FE El Other FEE INSPECTOR# 8788 PERMIT VALID I I �2&Ze� to ll1 ❑ Food Hantiler a ❑ Check# AMOUNT PAID Date I t Y ?iD Ji INVOICE# (tiL ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date l( 48-02-034 / 1123/13 �� l/�� 2--,;, MASTERFILE R COR INFORMATION PINK J� �l t