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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at ExistingFacility CiNew EH Program and New Facility [Facility ID Program Record ID Facility Address 147 :) lnl l n > I f ;�V z . —Fr- -7(p (Please check the appropriate description and specify size, number of units and periinent 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 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 ❑ II Plant 11 Produce Stand El '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-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number FOMENT SOLID WASTE PROGRAM (4400) � � � ❑ Landfill El Transfer Station ❑ Ag/Cannery Waste Site sh Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facilityq},��rtdfir ❑ Refuse Vehicles(#of Units) ElDumpsters>20 cu yd (#of Units) E m 7 Cleanup Site MEDICAL WASTE PROGRAM(4500) SAN JOAQUIN COUNTY ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Gene04dtRCMi f tuler ❑ Transfer Station 11Veterinary Clinic El Common Storage Facility 1:12- 10 ❑ 11HF�-TH bP> generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERG NCY NOTIFICATION FOR THIS FA LITY AND/OR PROGRAM CONTACT PERSON 11 G ( Day P c JD — 5-)30Night Ph PROGRAM ELEMENT I (� !J FEE ff r r ❑ Surcharge FEE ❑ Other FEE INSPECTOR# nh Cc r e S PERMIT VALID r 1 t0 ❑ Food Handler ❑ Check# AMOUNT PAID�� -0 Date �L INVOICE# Cash REVIEWED BY ACCOUNTING OFFICE Date I 8-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13