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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility lew EH Program and New Facility Facility ID UDOz�2`t/ Program Record ID OCT 24 2098 Facility Address 7d j/ .5;fVa yadu � /l � heusQ -A.95 1R MMSIVTALHekTH (Please check the appropriate description and specify size, number of units and pertinent information.) ERVICES FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES Z No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments TrPrepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility --Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event---Dates of operation from to W CFO ❑ AXB 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 Facilit,pgYA,c El Waste Generator(2200)----------> Tons Generated Per Year F ENr El Tiered Permitting Facility-------> 11 CA(2232) El CE (2233, 2234, 2235, 2237) 11PBR (2231) ftf 36) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs OCT 2 4 ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ?418 ❑ Other CUPA Program -'%ftJOAQIII HOUSING PROGRAM (2400) HEALTH ONMENE JV TY ElHotel/Motel------Number of Units El Jail or Exempt Institution ----Number o��'r##RT � Employee Housing (2700) Use Employee Housing/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 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 Ternp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration# 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 ❑ 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 ❑ 2- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Fonn EME G NCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM /Q CONTACT PERSON Sh(AhUk A Day Ph 2u ) 0- Night Ph (�01) 7416-1 70 PROGRAM ELEMENT�pI _ FEE ❑ Surcharge F E 1:1 Other FEE INSPECTOR# PERMIT VALID /D?S to 1�3r1 1 ❑ Food Handler ❑ Check# AMOUNT PAID 31b• Z) Date INVOICE# 3� 397 ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034l MASTERFILE RECORD INFORMATION PINK 1/23113 W]7 916