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r SAN J0AQU:1N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFII_E RECORD INFORMATION FORM _ C New EH Program at Existing Facility ❑New EH Program and New Facility ' vie-{ Facillt ID —1!N Old 1 bb1-O Program Record ID Facility Address 2-5�b2 S . Sch�-� 1 e C+ . (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 Markel 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 O Ice Plant❑ Produce Stand C] Special Event--Dates of operation frorn to ❑ CFO ❑ A ❑ BB DAIRY PROGRAM(2000) PAN El A Dairy ElGrade B Dairy ElMllk Dispenser-Number of Containers In M gly .CUPA Viet)11Hazardous Materials Business Plan (1900) Number of chemicals: ,,(('' t� ElCaiARP Program ❑ Program 1 Facility El Program 2 Facility ❑ Program 3 Facility�A Y 2019 ElHazardous Waste,Generator(2200)----------> Tons Generated Per Year SANJOAQU ❑ ��Tiered Permltting Facility--- --> ❑ CA(2232) 11CE(2233,2234,2235,2237) El (2231 ❑ Aboveground Storage Tank Facility(AST)(2800) Number of ASTs N�EPARTMFNT ❑ Underground Storage Tank Program (UST)(2300) Use UST A and B forms ❑Other CUPA Program HOUSING PROGRAM(2400) ❑ HotellMotol-----Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing(2700) Use Employee Housing/Labor Camp Application Farm SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL.(3000) ❑ Environ ental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UiC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quallty 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) 1 ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art Facility-Single Use (4120) j ❑ Body Art Facility-Sterilization(4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Moble Facility(4131) LIQUID WASTE PgOGRAM(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 1 ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (a or units) ❑ Dumpsters> 20 cu yd(tt of units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTh 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 Form l EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM 4 CONTACT PERSON Q__006+ c'_ k V\ Day Ph ZO � 5i Z� _j 51&t Ph r GRAMELEMENT `�7` FEE 2 S`�" ❑ Surcharge EE ❑ Other FEE ECTOR# PERMIT VALID // /` to 3( Zb ❑ Food Handler heck# AMOUNT PAID �� Date INVOICE# 3L Cl Cash REVIEWED BY ACOouNTING OFFICE _ DateIL_ -- 48-02-034 J MASTERFILE RECORD 1 FORMATION PINK1/2311 1123113