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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM :1 ❑ New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID G0)-6,2-- Program Record ID ( D O Facility Address '725e'' �- lC (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 Market only ❑ Multiple Departments❑ Prepackaged Goods Only Mobile Food Vehicle--Make 0A Ll r'` Vehicle Type Color Registration# License# ZY -7-b 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) ❑ PER(2231) ❑ PER 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 - El Jail or Exempt Institution----Number of Units Employee Housing(2700) Use Employee Housina/Labor 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-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 of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ SI a/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ ' e ❑ Refuse Vehicles (#of units) ❑ Dumpsters>20 cu yd(#or Units) ❑ Ran _ nup Site MEDICAL WASTE PROGRAM(4500) �,/�7�� 6I D ❑ Primary Care C1 Acute Care El Skilled Nursing ❑ Large Generator 11 Small Genei`$t8Y 19 I�f�te,d Hauler ❑ Transfer Station ❑ Veterinary Clinic 13 Common Storage Facility ❑ 2- 10 ❑ flJgNfj� > c�nerators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form 4VjAONINC N Ty EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM H THDEp FNTqL CONTACT PERSON a-7 Day Ph Night Ph �141ENT PROGRAM ELEMENTT/ r FEE 2✓T 13Surcharge FEE 11 Other FEE INSPECTOR# 33/a PERMIT VALID2,� t0 2� El Food Handler ❑ Check# AMOUNT PAID u✓ Date I I t2 2-0 INVOICE# 344 ❑ Cash C99A REVIEWED BY I ACCOUNTING OFFIC E ' Date /0-7/20 48-02-034 MASTERFILE RECORD IN ORMATION PINK 1/23/13 60y* 11 t�I t5