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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existin2 Facility ❑New EH Program and New Facility Facility ID DQ2(a� Program Record ID Facility Address_ I'M S . i wioy\ S+ S+0ctc4-0,' O 9 5-Z o 6 (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 ❑ bAultiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Lin AA(_ Vehicle Type ?TV) Color Registration# License# 7— 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: ❑ 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 A and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ Hotel/Motel--Number of Units - EI Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP 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) A El Landfill 1:1 Transfer Station ElAg/Cannery Waste Site 1:1Slud As N1. 11 Waste Tire Facility El Compost Facility ElProcess/Recycle Facility 11 CIA L ❑ Refuse Vehicles(#of units) 11Dumpsters>20 cu yd (#of units) 11Farn##ch leak� ite MEDICAL WASTE PROGRAM(4500) MH( 13 99 El Primary Care El Acute Care ❑ Skilled Nursing El Large Generator ❑ Small Genera§*d Ited HgL(er 13TransferStation 11 Veterinary Clinic ❑ Common Storage Facility El -10 1111 -6A�f/1176 :&t1wws PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form 110,,, T NT EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON L QQ`hel LU(2 if Day Ph 52 S'!f6 :77f Night Ph -70q S Ve 7317 PROGRAM ELEMENT�6 2p- FEE -7., ElSurcha ge FEE El Other FEE INSPECTOR# CN9)�7Z PERMIT VALID t0 I ❑ Food Handler./ 11Check# AMOUNT PAID �� Date /.1 INVOICE# �2400 ❑ Cash R E V I EWS By ACCOUNTING OFFICE Upy, Date 1/23/1334 IN 12325338 MASTERFILE RECORD INFORMATION PINK