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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑New EH Program at Exist ng Facility Nei•,EH Pro ram and New Facility Facility ID 15 (70 $ Program Record ID � Facility Address 2?t_/-� I . ��- cit' ir,-< C' i� 95-311 (Please check the appropriate description and specify size number of units and pertinent information i FOOD PROGRAM(1600) Restaurant Seating Capacity_ Square Footage Food Handlers Course required: YES❑ No❑ 13 Commissary ❑Dry storage on,y ❑with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market---Square footage ❑w'Meat Market only ❑Miltlple Departments❑Prepackaged Goods Only ❑ Mobile Food Vehicle -Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Colof 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 pAIRY 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(12200)----------> Tons Generated Per Year ❑Tiered Permitting Facility-------> ❑CA(2232) ❑CE 12233 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 HousinglLabor 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-NPLJSEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility_ ❑Pool ❑Spa ❑Out of Service PoollSpa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑Poultry Farm-------Maximum number of birds ❑Kennel TATTOO,BODY PIERCING PERMANENT COSMETIC PROGRAM 14100) ❑ 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# L,cense# 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 ❑Waste Tire Facility ❑Compost Facility ❑ Process/Recycle Facility ❑CIA Landfill Site ❑ Refuse Vehicles I#y u.,s ❑ Dumpsters>20 cu yd #o'u^s ❑Farm/Ranch Cleanup Site MEDICAL WASTE 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 14600)Use PWS EHO 46-02.003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON _ K Day P ` `> >` tcG Night Ph PROGRAM�V� F ❑ Surcharge FIE ❑Other FEE . INSPECTOR T VALI z T� t0 3 ❑Food Handler ❑Check# PAI dV Date LhJ INVOICE# c ❑Cash REVIEWED BY ACCOUNTING OFFICE Date LJ 49-02.03a 1'23!13MASTERFILE REtORD INFORMATION PINK