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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing F cihty ❑New EH Program and New Facility Facility ID t- D7� 0 Program Record ID �l��f39�� J Facility Address _3SSD T--A • W'11160(,� \'4 (Please check the appropriate description and specify size, number of units and pertinent information.) 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 DepartmentsPrepackaged 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 ElIce Plant ElProduce 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-------> ❑ CA(2232) ❑ CE (2233, 2234, 2235, 2237) ❑ P B R (223 1) ❑ PBR 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 EmploVee 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 Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration# License# Capacity AbA Vehicle# ElPumper Yard ElPackage Treatment Plant ❑ Chemical Toilet /� f Units SOLID WASTE PROGRAM (4400) CFS ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste SiteC, ®udge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facilit% Q ?6CIA Landfill Site El Refuse Vehicles (#or Units) 13Dumpsters> 20 cu yd tttofpppf�j.q��, Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) T RCN,yF 4V ❑ Primary Care El Acute Care El Skilled Nursing El Large Generator �eltor El Limited Hauler El Transfer Station 11 Veterinary Clinic El Common Storage Facility 1:12- 10160 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form „T" , � EMERGENCY NOTIFICATION FORTHIS FACILITY AND/OR PROGRAM CONTACT PERSON (�;Gl /�1j� O� ?� Night P �'`t?0—( eg PROGRAM ELEMENT I V FEE �/ ❑ Surcharge FE ❑ Other FEE INSPECTOR# PERMIT VALID 2- 10 t0 I , l Food Handier /- ❑ Check# AMOUNT PAID 6C Date 1 DICE# Cash REVIEWED BY ACCOUNTING OFFICE Date l 48-02-034 MASTERFILE RECORD IFORMATION PINK 1/23/13