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SAN JOAQUIN COUNTY E._ RONMENTAL HEALTH DEPART, ANT MASTERFILE RECORD INFORMATION FORM PAYMENT ❑ New EH Program at Existing Facility Mew EH Pro ram and New Facilit FticelvF-Q Facility ID Program Record ID May 13 2014 Facility Address 7 `�cJ nP e Q 9metATAL �0 3(0 SAN JOAQUIN COUNTY ( appropriate P specify_ ) HEALTH D� FkTfA Please check the ro date descri tion and eci size, number of units and pertinent information. ARtMENT 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 Vehilhe Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant ❑ Produce Stand ❑ Special Event---Dates of operation from to WCFO ❑ A W DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dalry ❑ 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) ❑ PER 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 Emp/ovee Housing/LaborCamp 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 Remedlation 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 VehicleRegistration# License# Capacity 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 ' EJ Refuse Vehicles( of units) 11Dumpsters>20 cu yd(#of units) 11Farm/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- 10 011 -60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form - E ERG NCY NOT( (CATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON �_� Day Ph ' _ -r7 ght Ph PROGRAM ELEMENT FEE r _ n 11 Surcharge FEE 11 Other FEE INNSPECTOR# PERMIT VALID t0 ❑ Food.Handler 'tLJ Check# AMOUNT PAID Date - INVOICE# ❑ Cash REVIEWED BY LL[ ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 1123113