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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM I 1 Now FH Prnnram nt Fricfinn Facility Mtl/aw EH Proaram and New Facilitv Record ID Facility Address q11 &.IC/& S;1, gzzf -0 70z -,q9 G9 9.r3 (Please,' check the appropriate description and specify size, number of units and pertinent information) FOOD PROGRAM (1600) VECTOR CONTROL PROGRAM (4000) - ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES E� 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 Type Calor 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 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: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator (2200)—> -Tons Generated Per Year ❑ Tiered Permitting Facility —> OCA(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 CU PA Program HOUSING PROGRAM (2400) ❑ Hoibi/Motel --Number of Units ❑ 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 ❑ NPL/SEP 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 Ccord (4130) 13Body Art -Temp Event Mobile Facility (4131) LIQUIDWASTE PROGRAM (4200) ❑ Pumper VehicleRegistration # License # Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets —Number of Units SOLID WASTE PROGRAM (4400) R9 ElLandfill13Transfer Station 13Ag/Cannery Waste Site ❑ Sludge/As'q �N ❑ Waite Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility [3 CIA Land II 0,L. l El Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd (# of Units) ❑ Farm/Rarleb Cleatu� MEDICAL WASTE PROGRAM (4500) % 04 n//'� ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ,1Q4 l HaA?l ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 -10 ❑ 11 - 60 H�@O/q�19T0S PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form 'Y /nt� EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON tt �l (LUC/C,cr Day Ph 5 31) JT( -5"K2i Night Ph PROGRAM ELEMENT UO"( FEE 1 VU ❑ Surcharge FEE ❑ Other FEE INSPCE�C,tTpR # L,. (NV\o%Le% PERMIT VALID k 0 -'l - to 10 --3 -�, 12. ❑ Food Handler ❑@hepk#, 1152 IiAMO/U�N�T,1PAID { 55 Date C>jq� L-1 INVOICE# ❑ Cash 0AJ REVIEWED BY t-,(/(I/L r VI S' ACCOUNTING OFFICE (,►,(rte Date I 1/23113'