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SAN JOAQUIN COUNT -NVIRONMENTAL HEALTH DEPA MASTERFILE RECORD INFORMATION FORM V� ❑New EH Program at Existing Facili ❑New EH Pro ram and New Facility5 � FacilityID C7bz `(j Program Record ID Kb5 2Srvv,RoFP 1 2023 Facility Address Z- 5 M iij ;-t (Please check the appropriate description and specify size,number of units and pertinent information.) SRVjc �rJy FOOD PROGRAM(1600) ❑Restaurant Seating Capacity Square Footage Food Handlers Course reguired: Yss❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation []Vending Machines Number of Units ❑ Retail Market—Square footage ❑ wlMeat Market only ❑ Multiple Departments❑ Prepackaged Goods OMy ❑ Mobile Food Vehicle—Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker#1 ❑ Temporary Food Facility—Dates of operatio from to ❑ Ice Plant❑ Produce Stand 0Speciai Event—Dates of operation from }c� -7 2 2 3 to _(e> 1-c 1 3 ❑ 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 arrd 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 Housinq/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM!(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ 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) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM_(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ElPackage Treatment Plant ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ SludgelAsh Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles M of Unda) _ ❑ Dumpsters>20 cu yd m oa unds) ❑ FarmlRanch 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 EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THis FACILITY ANDIOR PROGRAM CONTACT PERSON tkA A tJ A S r��1 A K M rA 1J,�i A L Day P h -3 9 -G -rt x- ri Night Ph PROGRAM ELEMENT \ 1C_7CA 75 FEE 4iLl ❑ Surcharge Few ❑ Other FEE INSPECTOR# J��{ PERMIT VALID to 1 I S' z - ❑ Food Handler ❑ Check# AMOUNT PAID Date T7 INVOICE# ❑ Cash REVIEWED BY A 0UNTING OFFICE Date 48-02-034 MASTERFILE RF ORDINFORMAl10N PINK W3/13