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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Pro ram at ExIstInQ Facility_ _ [:]New EH Program and New Facilit Facility ID t0241 Program Record ID T4CG4g'S qS �( Facility Address_ 411 1; - 111A ron 1kt we Sk C %3'rvG1Uvn Ca, G1 b e Uu (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 ❑ 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: ❑ CaIARP 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 11 Pool ❑Spa ❑Out of Service Pool/Spa VECTOR CONTROL PROGRAM (4000) 11 Poultry Farm -------Maximum number of birds TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) Body Art Facility-Sine04720P023 Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) SAN JOAQUIN COUNTY ❑ Pumper Vehicle Registration # License # Capacity HE MENTrAEL� ❑ Pumper Yard El Package Treatment Plant El --- Chemical Toilets -Number of Units �f ❑ N atural Bathing Area PAYNiEIV I �tLt�EIVED SOLID WASTE PROGRAM (4400) [I Landfill El Transfer Station ElAglCannery Waste Site ❑Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (4 of Units) ❑ Dumnsters > 20 .0 vd rtl tInhsi ❑ FarmlRanrh Claamin Sita 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 46-02403 Blue Application Form f Pur* _cmJ v KIn7AC1/ AVJ^&t 0^0 VU10 i-Af�ll ITV ♦&Inl^n 120^^-t3A11A CONTACT Day Pi _20Fi c PROGRAM ELEMENT HI,�C� FEE ,a c,� - ❑Surcharge INSPECTOR #PERMIT VALID t 7 Z-3 t0 �/ 36, r❑ check # AMOUNT PAID 3 Date °1 - C9 Cash REVIEWED BY I1 ACCOUNTING OFFICE 2-034 1123/13 48-0 P � � f• � � s C C. l 'fw j_GNight Ph ❑ Other FEE 11 Food Handler INVOICE # S$ Date `l 323