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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT EMASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existin Facility ❑New EH P;r�/off ram and New Facili Facilit ID 3S'S Pro ram Record ID -7 PDS J�.� Facility Address 144 S b v (h d oo�c CN 9 c3� 1 (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 91 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 Vehicle TypeColor Registration# License# 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 [R CFO Q 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 Ae ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE(2233,2234, 2235, 2237) ❑ PBR(2231) ❑ PBI� A, ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs C T ❑ Underground Storage Tank Program(UST) (2300) Use UST A and B forms IC `'VFQ ❑ Other CUPA ProgramHOUSING FB t7 y ❑ Hotel/Motel PROGRAM(2400) of Units ❑ Jail or Exempt Institution ---Numb�✓O�gpQU/N CO '? SITE MITIGATION(2900)Employee Housing ) Use Employee Housing/LabNDERGROUND INJECTION ONTROL(3000) 'or Camp Applicatio FormH p'J� ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP 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) ❑ 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 ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles I#of 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 112- 10 ❑ 11 -60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form �7 EMERG NCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM 1 99 CONTACTPERSON &tnvl/ I c' DayPh (. -U _ 2NightPn��C 'LwI �1�SZ PROGRAM ELEMENT U FEE JC ❑ Surcharge 1 ❑ Other FEE INSPECTOR# I- PERMIT VALID Z t0 ZO � ❑ Food Handler ❑ Check# AMO TPAID .0 Date 2 INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 4&02-034 n^. I -3� y MASTERFILE RECORDINFORMATION PINK 1/23/73 l,��rL