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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM '❑ New EH Program at Existing Facility W.-2w EH Program and New Facility cy ID (�b,2Sb` Program Record ID 2 Failit Facility Address1D13 1�,�SDtJ c1- -yt% t-e- i —fi J C-1c7SZv" (Please check the appropriate description and specify size, number of units and pertinent information.) F09D PROGRAM(1600) Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ Ll 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 Registration# License# Sticker# ❑ Temporary Food Facility--Dates 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-------> ❑ CA(2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ 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 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 Temp Event Co-ord (4130) ❑ Body Art-TTA-X Event Mobile Facility (4131) LIQUID WASTE PROGRAM(4200)ElPumper VehicleRegistration# License# Capacit %Vehicle# El Pumper Yard El Package Treatment Plant ❑ Chemical Toil sQ� mb r nitSrl SOLID WASTE PROGRAM (4400) e % OJT C G CP?'GS� ❑ Landfill 13 Transfer Station ❑ Ag/Cannery Waste Site o��' C��L�_lr�l sh Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility atandfill Site ElarRefuse Vehicles (#or Units) ❑ Dumpsters> 20 cu yd (#of Units) arm m/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) �`Cf ❑ 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 Form V EMER ENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON K�I�V1Gt l 31 VV,'j U Day Ph2(206]-� (lam—ZZ` Night Ph PROGRAM ELEMENT 2-CS FEE ❑ Surchar e F-7. ❑ Other FEE INSPECTOR# 01S'�Z PERMITVALID 2 'Z1 \� t0 �Z 5\ t-� ❑ Food Handler ❑ Check#VLS-0— AMOUNT PAID 3��P�� Date 12 l IQ INVOICE# ❑ Cash REVIEWED B ACCOUNTING OFFICE Date .2 7 48-02-034 MASTERFILE RE ORD WORMATION PINK 1/23/13