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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PgyMeN MASTERFILE RECORD INFORMATION FORM Rec' ;V r ❑ New EH Program at ExistingFacility ❑New EH Program and New FacilityE, Facilit iD 6026 Pro ram Record ID lel'} SAN JUN 24 2�2� Facility Address I*a05 tPJ&5ta A� H�ENVIR QU/cotj (Please check the appropriate description and specify size number of units and pertinent information.) ALrH DFpA& A Nr ;FOOD PROGRAM(1600) ,_,Restaurant: Seating Capacity. Sl Square Footage Ir©-50 Food Handlers Coarse required: YEs 06 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 A Vehicle Type Color Registration# PUM License# Sticker# ❑ Mobile Food Prep Unit-Make Vehicle Type Color Registration# ILicense# Sticker# ❑ Temporary Food Facility-Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event--Dates of operation from to f❑ 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}------>-Tans 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 USIA and forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel--Number of Units ❑ Jail or Exempt Institution--Number of Units Employee Housing(2700) Use Employee HousinglL bor 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-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 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) ❑ 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 ❑ AglCannery Waste Site ❑ SludgelAsh Site ❑ Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of units) ❑ Dumpsters>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 112-10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THis FACILITY AND/OR PROGRAM CONTACT PERSON 1TT€P1 hJ DA4.ioAc7-� - - - Day Ph p - - E/S ANightPh o?a9- 'l Bl q8 PR GRAM ELEMMENT 2. FE 35 ❑ Surcharg FEE ❑ Other FEE INSPECTOR# O PERMIT VALID z to ❑ Food Handier ❑ Check# �� AMOUNT PAID • Q Date INVOICE# c3 ❑ Cash REVIEWED 8Y ACCOUNTING OFFICE Date laz Z 48-02-034 ,y MASTERFILE 1E1111 1 4RMATION PINK 1123113 //�'f/ 1'7 73 77 9�