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SAN JOAGlUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT I <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existin Facilit []New EH Program and New Facility <br />Facilit ID CO�Ljg Program Record ID <br />Facility Address zl l E MAA-e4n L41y,%* ,sh G S veA un CA 1526 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity. Square Footage Food Handlers Course required: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Temporary Food Facility --Dates of operation from to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to ❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200) ---------->-Tons Generated Per Year. <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑PBR (2231) ❑ PBR HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ HotellMotel ------Number of Units ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Emploves Housing/Labor Camp, Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 11 Pool ❑Spa ❑ Out ^4:4z i <br />Pool/Spa <br />VECTOR CONTROL PROGRAM (4000) <br />El Poultry Farm -------Maximum number of birds <br />TATTOO, BODY PIERCING, <br />PERMANENT COSMETIC PROGRAM (4100) <br />❑ Natural Bathing <br />Area <br />L SENT <br />IVE® <br />18I Body Art Practitioner Reg (4110) ❑Mechanical DSPS Nocation (4115) <br />El Body <br />❑Body Art Facility-(�,1�_0� <br />Body Art Facility -Sterilization (4121) Body Art Temp Event Co-ord (4130) ❑Body Art -Temp Eve M t e f�� y (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ SAN JOAQUIN COUNTY <br />Pumper VehicleRegistration # <br />❑ <br />License # <br />❑ Package Treatment Plant <br />Capacity ENVI�igAI <br />Pumper Yard <br />❑ Chemical Toilets ----Number o T REPARTMENT <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill 11 Trans Station ElAglCannery Waste Site ❑Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles f#of Unttsl ❑ Dtimnstt3rs > 9(1 rni vd r#nf I tnitcl 11 RarmlRanrt+ r nanun Rifn <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT <br />Day Ph <br />PROGRAM ELEMENT_ t� II Z� FEE S � ❑ Si <br />Night Ph <br />INSPECTOR#PERMIT VALID (7 �.3 t0 <br />ElCheck # AMOUNT PAID 315 Date <br />Ig Cash REVIEWED BY ACCauNTING OFFICE <br />48-02-034 <br />1/23/13 i �O Col q <br />CG I <br />❑Other FEE <br />❑ Food Handler <br />INVOICE il$ 35&z� <br />DateFILE RE <br />9 L� <br />9 <br />2 <br />