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SAN JOAQUIN COUNTY E ZONMENTAL HEALTH DEPAR' dT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility ❑New EH Program and New Facility acility ID 2Sj $ Program Record ID s Facility Address \':-\-4 S_ 0� S� c--f ° `�,kW -DbG ,P (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 ❑ etail Market----Square footage Elw/Meat Market only El Multiple El Departments Prepackaged Goods Only Mobile Food Vehicle--Make Vehicle Type Color Registration# License# 44 L4--�' 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 Housinq/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) p/�� Number of Pools/Spas at Facility El Pool El Spa ElOut of S�i4li M"IP ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) RECEIVED I—] Poultry Farm-------Maximum number of birds ElKennel J TATTOO, BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) UN 2 4 2019 ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (41��Q 6AArt 'Facility-Single Use (4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4 C mp Event Mobile Facility (4131) LIQUID WASTE PROGRAM(4200) TH OEP TMENT ❑ 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 ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (#or Units) ❑ Dumpsters> 20 cu yd (#of Units) ❑ 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 (4600) Use PWS EHD 46-02-003 Blue Application Form AL ,r EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON ! rl� V�� G�. Day Ph W—Ljk5'C1'11 Night Ph PROGRAM ELEMJEN _ `U FEE `� ❑ Surchar a FEE ❑ Other FEE �S, ECTOR# - l PERMIT VALID `[ t0 I a � ❑ Food Handler Check# �lC� AMOUNT PAID 3 U7C Date 6 (� I VOICE# 0Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MA TERFILE REC RD INFOR AT ON PINK 1/23113 1�(_ _ r —}-{— ti�-` q