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SAN JOAQUIN COUNTY &IRONMENTAL HEALTH DEPAF*ENT <br />MASTERFILE RECORD INFORMATION FORM <br />L-, I II VYIdIII dl cxJsung racwty PLNew EH Program and New Facility <br />Facility ID 6Ln0 ZZQZLe Program Record ID � K2 1)"12) 4 Z6Ikl -1 l <br />Facility Address X500 E. Lo u t5e -Ave La -t-( r <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM If 600) <br />❑ Restaurant: Seating Capacity— Square Footage Food Handlers Course required: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />❑ Temporary Food Facility --Dates of operation from to <br />❑ Special Event ---Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Sticker # <br />❑ Ice Plant ❑ Produce Stand <br />El CFO ❑A❑B <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA — <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program 1:1 Program 1 Facility El Program 2 Facility__❑ Program 3 Facility <br />"El <br />Waste Generator (2200)----------> Tons Generated Per Year `; <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PER (2231) ❑ PER HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel ------Number of Units ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility_ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds ❑ Kennel <br />TATTOO, BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # License # Capacity Vehicle # <br />11Pumper Yard 1:1Package Treatment Plant ElChemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles I# of Units) ❑ Dumpsters > 20 cu yd (# of Units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAM ELL.E�MEN/TT aaa3 FEE o�t3 ,r� EI Surcharge FEE T_I1:1 Other FEE <br />INSPECTOR# "f ( PERMIT VALID 'V I to DI�- ZD I-� ❑ Food Handier <br />�L <br />❑ Check # AMOUNT PAID Date INVOICE # �2 <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE j,4 Date ,fir I <br />1/23/13 V-01 MRnLL Mi= ,UKU INhUKMH I JUN PINK <br />