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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 'AqC��T MASTERFILE RECORD INFORMAT ORM M ew EH Pro ram a�Exjstlng Facili w EH Pro ram and New Facili S 4�0Ir Faciiit ID � Pro ram ecord ID /2� $3 Facility Address L,- 2.-�'K�=-FCG� (Please check the appropriate description and Specify size, number of units and pertinent information.) Rr�F" Ty FOOD PROGRAM (1600) T- ❑ 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 ❑ wlMeat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License 9 Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type COIOr Registration# License# Sticker# Temporary Food Facility--Dates Of operation from 2'3 to 4 Z ❑ Ice Plant❑ Produce Stand ❑ Special Event---Dates of operation from to El 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) ❑ PER HHW(2236) ❑ Aboveground Storage Tank Facility(AST)(2800) Number of ASTs I-] 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 Carrito Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ u1C Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remedlation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service PoollSpa ❑ Natural Bathing Area 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) Cl Body Art Facility-Sterilization(4121) ❑ Body Art Temp Event Co-ord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) L1gIJID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# _ License# _ Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ AglCannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(a ofUnits) ❑ Dumpslers>20 cu yd(#orunits) ❑ Farm/Ranch Cleanup Site 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 END 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY A WOR PROGRAM CONTACT PERSON�71 cIC.HRP17 L-- L 1 Q0 Day Ph / ^q ght Ph PROGRAM ELEMENT FEE ) S.6 El Surcharge FEE ❑ Other FEE a INSPECTOR# �r'� PERMIT VALID ~, 3�z2. to -t f;c _i ❑ Food Handier Q Check> �: AMOUNT PAID_ = ti% Date a3 INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE i Date 46-02-034 123 3 1123113 MASTERFILE RECORD INFQRMAT ?INK