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I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR—BENT MASTERFILE RECORD INFORMATION FORM PAYMENT ❑ New EH Program at Existing Facility ew EH Pro ram and New Facility RECEIVED Facility ID 0023 4t Pro ram Record ID & JUL'2 4 2015 Facility Address i CXD /t C, SAN JOAQUIN COUNTY (Please check the appropriate description and specify size, number of units and pertinent information.) HENVIROMENTAL EALTH DEP 7MENT 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 ❑ccc,,, Retail Market---Square footage ❑ w/Meat Market only ❑ Multiple D`eQartments❑ Prepackaged Goa Only Mobile Food Vehicle--Make �(�£U TNCLII��Ct� Vehicle Type ST�� I�^t Color_ E T Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# /cense Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant O 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) ❑ PER HHW(2236) O 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 Fon) SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment El UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP 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) ❑ Kennel ❑ Poultry Farm-------Maximum number of birds 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) ❑ Sludge/Ash elAsh Slte El Landfill ❑ Transfer Station 1:1Ag/Cannery Waste Site 9 ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (#of Units) ❑ Dumpsters> 20 cu yd (#atunlls) ❑ 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- 10 011 -60 ❑ > 60 generators PUBLIC WATER S1rSTE PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form �_ _ E ER NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM ,Q CONTACT PERSON /�VrW7�Lc��_w D� Day Ph • 10.5k<d�NighI PhOt1 0 s(O�CJ PROGRAM ELEMENT r FEE ❑ Surchar a FE ❑ Other FEE INSPECTOR# /Or PERMIT VALt0 ❑ Food Handler Check# Sl AMOUNT PAI3. a_ DatZept— )�)094 INVOICE# Cash REVIEWED BY ACCOUNTING OFFIC Date 7 J MAATFRrn FprnoMn INFr)RMATION PINK