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�f SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM AyMENI' t8INew EH Proram at Existin Facllit RECEIVE,) ❑New EH Pro ram and New Facllit Facility ID Pro Record ID Facility Address NA 5, 5 ;ram I-001 CA MAY 27 2M (Please check the appropriate description and specify size,number of units and Pertinent Information.) SAN JOAQUIN C FOOD PROGRAM(1600) ENVIR�OEf�p� CONTAU TY ❑Restaurant: Seating Capacity_ Square Footage Food Handlers Course required:HqA� "'RTMENT ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines Number of Units - Ig Retail Market—Square footage _72-0 ❑w/Meat Market only ❑ Multiple Departments 121 Prepackaged Goods Only O Mobile Food Vehicle-Make Vehicle Type Color Registration If License# Sticker# ❑ Mobile Food Prop Unit--Make Vehicle Type Color Registration If License If Sticker# ❑ Temporary Food Facility--Dales 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 8 Dalry ❑ Milk Dispenser-Number of Containers in Mulli-Head Unit_ CU A ❑ Hazardous Materials Business Plan(1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility Cl 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 ❑Jafl or Exempt Institution---Number of Units Employee Housing(2700)Use Emplovee HousinglLabar Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC site ❑Abandoned HW Site ❑non-NPLISEP 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) i ❑ Poultry Farm---Maximum number of birds ❑ Kennel i TATTOO.BODY PIERCING.PERMANENT COSMETIC PROGRAM(4100) ❑ Body Art Practitioner Reg(4110) ❑ Mechanical OSPS 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 VehicleRegistration If 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 to of units) ❑ Dumpsters>20 cu yd(a or units)_ ❑ FarmlRanch Cleanup Site MEDICAL WASTE PROGRAM(4500) -.,�- 13 Primary Care ❑ Acute Care ❑Skilled Nursing ❑ Large Generator ❑ Small Generator ❑Limited Hauler ❑Transfer Station ❑Veterinary Clinic.r ' ❑Common Storage Facility ❑2-10 011-60 ❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46.02-003 Blue Aopfico#on Form MERG NOTIFICATION R IS FACILITY ND/oRP GR CONTACT PERSON PnJ Day Ph 7±4- 3)1 -0076oght Ph �i31-oN�7b W= PROGRArA ELEMENT'r} Z FEES ❑ Burch rge FEE 13 Other FEE t r INSPECTOR# 922 Sl PEF%mrr VAUD in to � ❑ Food Handler Check A /�R`,�- AMOUNT PAID Date �- il= INVOICE# r, Cash REVIEWMUY AccoPnTwGOFFK �� Date4j 2 I 40.02-034 , rMSTril"LEFRCORD INFORMATION PUN I W3113 f