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7 SAN JOAQUIN COUNTY ENVIRONMENTAL HE ALTH FORM 1 MASTERFILE RECORD INFORMATION FB 11 I'll 2 ❑New EH Pro ram and New Facili S VO R6 Q0/E❑ Nevi EH Pr ram a ExistingFacility� r A(, c 002 �N �fT YFacllit ID �-5 Facility Address'3225 {P;ease chock the appropnate description and specify size. number of units ar)d pertinent information.) T I FOOD PR99&A 1(1600) Food Handlers Course required: Yes❑ No ❑ I ❑Restaurant Seating Capacity_ _ Square Footage_ — ❑ Commissary ❑ Dry storage unly ❑ with Food Preparation ❑Vending MachinesNurnber of U^:Its ❑ Retail Market---Square footage_ ❑ wmew P,larket only ❑ hlulrip'=e Departments❑ prepackaged Goods Orly Vehicle Type — -- Color _ ❑ Mobile Food Vehicle -f4take_ License#— St,cker# - I Registration# — _ Color Vehicle Type_. — ❑ Mobile Food Prop Unit--Make_ License#. StUckel# -- Registration#_ to — ❑ Ice Plant❑ Produce Stand ❑ Temporary Food Facility--Dates of operation from y to � ❑ CFO ❑ A ❑ B ® Special Event--Dates of operation from DAIRY PROGRAM (2000) ❑ Milk Dispenser-Number of Containers in Nufa-Head Unit ❑ Grade A Dairy ❑ Grade B Dairy C_UP A a and ard Program Materials Business Plan(1900) Number of chermcals _ ❑ Hazardous _ ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility 0H ❑ Hazardous Waste Generator(220C)---------'-Testis Generated Per Year—_ Tiered Permitting Facility-------' ❑CA(2232) ❑ CE (22.33.2234, 2235. 2237) ❑ PBR(2231) ❑ PBR HHW ,2236; ❑ Aboveground Storage Tank Facility(AST) (2800) Numbe-of ASTs— ❑ Underground Storage Tank Program(UST)(2300) Use UST A and B forms — ❑Other CUPA Program —_ HOUSING PROGRAM(2412,0) — ❑ Jai(or Exempt Institution--Number of Units ❑ Hotel/Motel---Number of Units Employee Housing(2700)Use Employee Housin /Labor Cam Application Form SITE MITIGATION.,2S00j i'vL�ERG,�O�1ND INJEGTI^..N C_ONTRCSL i,3lh0Q;i te SEP Cleanup Site te ❑ Environmental Assessment a non-CAPS it Cleanup cal HSite ❑ leanu Cleanup❑Site U ❑ UIC l ❑ Water Quality Remed ationSite ❑ Abandoned HW Site RECREATIONAL HEALTH PROGRAM(3600) ❑ Pool ❑ Spa ❑ Out of Service PoollSpa ❑ Natural Bathing Area Number of PooI&;Spas at Facility — VECT R CONTROL PROGRAf4!(40001 ❑ Kennel ❑ Poultry Farm------f�'aximum number of birds TATTOO BODY PIERCING.PERMANENT COSMETIC PROGRAM 20 ❑ Body Art Practitioner Reg (41 101 ❑ Mechanical DSPS Notification(4115) ❑ Body Art Art-TampEve nglMobi a Facility(4''1) ❑ Body Art Facility-Sterilization (4121; ❑ Body Art Temp Event Co-ord(4130) ❑ Body LIQUID WASTE PROGRAM(4200i — — Capacl;y ❑ Pumper VehicleReaistration# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ---Nu'nnfr ul Units OLID WASTE PROGRAM 14400) ❑ SludgelAsh Site ❑ Landfill ❑ Transfer Station ❑ AglCannery Waste Site ❑ CIA Landfill Site ❑Waste Tiro Facility ❑ Compost Facility ❑ ProcesslRecycle Facility❑ UumF cl�,_ �20 cu yd ❑ FarmlRanch Cleanup Site ❑ Refuse Vehicles I= uressl _ MEDICAL WASTE PROGRAM(4500) D Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator1,1 .E0or 0Limited >60 q Hauler a ato�s ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 PUBLIC WATER SYSTEM PROGRAM 1,4600 I Use PWS EHD 46-02.003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM Dav Ph #Night Ph — CONTACT PERSON ❑ Other FEE FEE � ❑ 5urch rge F« PROGRAM ELEMENT . ❑ Food Handler PERMIT VALID —2 � tO IN CTOR# Date --1' AMOUNT PAID 2- IN':CIC` # heck# _L,3 - Date i Gosh R£VIEN'ED f3Y 1,"ASTERFILE RECO INFOP,M.tiT1C1v PINK •� .t�-02.434 1�2Jt3