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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD New EH Program at Existing Facility ❑New EH Program and New Facilit Facility iD FAOD77 7D3S Program Record ID Facility Address 0�1 j C Zc(6 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) Waste Site ❑Sludge/Ash ❑ 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 El Registration # License # Sticker # ❑ Temporary Food Facility --Dales of operation from to ❑ Ice Plant ❑ Produce Stand ❑ Special 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 -------> OCA(2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR 11Aboveground Storage Tank Facility (AST) (2800) Number of ASTs 11Underground Storage Tank Program (UST) (2300) Use USTA and B forms 11Other CUPA Program HOUSING PROGRAM (2400) (2231) ❑ PBR HHW (2236) ❑ Hotel/Motel------Number of Units ❑Jail or Exempt Institution ----Number of Units Employee Housing k Use Employee Housfng/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 fm 4 y ❑Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds ❑Spa ❑Out of Service PoollSpa ❑Natural Bathing Area ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) o 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 # 11 Pumper Yard SOLID WASTE PROGRAM (4400) License # ❑ Package Treatment Plant Capacity Vehicle # ❑ Chemical Toilets ----Number of Units ❑ M RGEN Y NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM I' ' - - CONTACT PERSON.V IC�k�I P L(.Y� Day Ph ? Landfill 11 Trans Station ElAglCannery Waste Site ❑Sludge/Ash Site El Waste Tire Facility ❑ Comp ost 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 d Hauler El Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility El - 10 ❑ 11 .60 rs PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form V _ ht Ph PROGRAM ELEMENT Lf 11C) FEE 4/S4/60?11Surc/har eFEEE11O q y INSPECTOR# 9136 PERMITVALID ��fttt.........2 2 22 t0 Co I60 ❑ Food 4444 ❑ check # AMOUNT PAID Date /� 22 INVOICE # f Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13