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SAN JOAQUIN COUNTY E' 'IRONMENTAL HEALTH DEPART -NT MASTERFILE RECORD INFORMATION FORM 1. ❑ New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID ,Q dtj?�3,3�" Program Record ID ApLq fs-73 Facility Address Ll o Lt �� (v , 10C- V,4-�_e_ f ' 4:5/4 .-k�( (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) ❑ 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 ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# Vs1pecial rnporary Food Facility--Dates of opera . n frorn ElIce Plant ElProduce Stand Event---Dates of operation from to ❑ 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: ❑ CalARP 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 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 ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ out�e-i I/Spa El Natural Bathing Area VECTOR CONTROL PROGRAM (4000) FC j ;r I-] Poultry Farm-------Maximum number of birds J//�� t VA ❑ Kennel TATTOO, BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) S VH / 20 El Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notificati p Bo Art Facility-Single Use (4120) El Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co- � �V GCF4 r Qrt-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) EpyRTMgi ❑ Purnper Vehicle Registration# License# Capacll ll 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 ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (#of Units) ❑ Dumpsteis> 20 cu yd (#of Units) ❑ 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 EHD 46-02-003 Blue Application Form EMERGEt4cX NOTIFICATION FOR THIS FACILITY AND OR PROGRAM CONTACT PERSON S c�r t Day Ph c1 9--S-0 2 ight Ph PROGRAM ELEMENT ILOrQ FEE ou ❑ Surcha ge F E El Other FEE INSPECTOR# PERMIT VALID IS I to �� 1 ❑ Food Handler lChe�c# as AMOUNT PAID Date 1v INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECOR INFORMATION PINK 1/23/13