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SAN JpAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM 71 ❑ New EH Program at Existing Facility New EH Program and New Facility- Facility ID GY72S76 3 Prograrn Record ID 42RD5 �X-4, Facility Address ��' �� Sfi A� C/1 (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 ;WRetaii Market----Square footage A 1-0.D_ - ❑ v, eat Market only ❑ Multiple Departments ElPrepackaged Goods Only ❑ Mobile Food Vehicle--Make L/QUOR SPORE 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: ❑ 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) ❑ 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 Forn? SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLtSEP 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 Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ SludgelAsh Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of Units) _ ❑ Dumpsters>20 cu yd (#or units) ❑ Farm/Ranch Cleanup Site McQICAL WASTET ( RAM(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 Fora/ EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM �/ CONTACT PERSON AI2� N &D q A Day Ph �d..Q �.�, _ t0 I ht Ph r ! 070 75 PROGRAM ELEMENT_ � 9--- FE ❑ Surcharg FIE ❑ Other FEE INSPECTOR# PERMIT VALID to .3 Zl� © Food Handier Gtr Check# AMOUNT PAID ;ZX Bate INVOICE# Cash REVIEWED BY ACCOUNTING OFFICE Date • 48-02-034 MASTERFILE RECO D INFORMATION PINK 1/23/13