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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facilit Faclll ID Program Record ID Facility Address e131 0o- Poioo- /v0•l1d JkCAL ( (Please check the appropriate description and specify size,number of un nd pertinent Information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capedty 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# Sucker# ❑ 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 Multl-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 S forms ❑Other CUPA Program _ HOUSING PROGRAM(2400) ❑ HotelfMotel—Number of Units ❑ Jail or Exempt Institution—Num'aer of Units Employee Housing (2700)Use Employee Housino/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3D00) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Poolispa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm--Maximum number of birds ❑ Kennel TATTOO BODYPIERCING,PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art FacllitySingle 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 VehicleRegistration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ ProcessiRecycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of units) ❑ Dumpsters>2D cu yd(#ei urns) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4600) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing fq 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 MERG CY NO CATIO FOR TMs FACILITY D/ R PROGRAM I CONTACT PERSON✓ pF L11-+ Q Day P Night PhAM- 4-11 -7W I PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMIT VALID t0 Ci Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED By ACCOUNTING OFFICE Date 48-02-OU MASTERFILE RECORD INFORMATION PINK V23113