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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM Pq yM El New EH Program at ExistingFacility ❑New EH Pro ram and New FacilityRF�F1 Facility ID Z Pro ram Record ID Sq APR 15 ZO Facility Address 09 b> 1 ScAte0c. Pi L -1 I-Cabi-ra> 95110 ENv gout ?1 (Please check the appropriate description and specify size.number of units and pertinent Information.) HeqLTN ol06 v FNOUNTy FOOD PROGRAM(1600) g RTAl ❑ Restaurant Seating Capacity_ Square Foolage Food Handlers Course mQuired: Yes ❑ NO ar ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending MachlnesNumber of Units ❑ Retail Market----Square footage ❑w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goode Only ❑ Mobile Food Vehicle—Make Vehicle Type Color Registration a License# Sticker# ❑ Mobile Food Prop Unit—Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility—Dates of operation from to ❑ Ica Plant❑ Produce Stand ❑ Special Event—Dates of operation from to aCFO I$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: ❑ CaIARP 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 Aand B forma ❑Other CUPA Program HOUSING PROGRAM (2400) ❑ HolallMotel--Number of Una•; ❑ Jail or Exempt Institution --Nur.lber of Units _ Employee Housing (2700) Use Emplovoe Houslna/Labor Camp Application Form SITE MITIOATION(2900) UNDERGROUND INJEGIIQN-4UN1 RUL (3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (36001 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 (4 t 16) ❑ Body Art Facility-Single Use (4120) ❑ Body Art Facility Sterilization (41211 ❑ Body Art Temp Event Coord (41,10) ❑ Body Art-Tomp Event Mobile Facility(,1131) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vohiele Registration # License a 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 Tim Facility ❑ Compost Facility ❑ Process/Recyclo Facility ❑ CIA Landfill Site ❑ Refuse Vehicles V,.r i1,--,%, ❑ Dumpstors> 20 cu yd it,,r��"a,� ❑ FarmlRanch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Cam ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Cllnlc ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PINS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR This FACILITY ANp/OR PROGRAM CONTACTPERSON - C Day Ph1,12 'JJ1.- Q NightPh1,15U_3pi437U PROGRAM ELEMENT FEE I S 5 ❑ Surcharg FEE ❑ Other FEE INSPECTOR LN(\� e PERMIT VALID to `f O ❑ Food Handler ❑ ch�•ek III k Cam- AMOUNT PAID / •� Date INVOICE# 3 ❑ CIO, REVIEWED BY ACCOUNTING OFFICE Date 1=1113 r Cc— _ c ^� MASTERFILE RrCOr INFORMATION PINK