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;SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ' MASTERFILE RECORD INFORMATION FORM ❑ New EH Pro ram at Existing Facility ❑New EH Program and New Facility w Facili ID _Program Record ID Facility Address_ S&)%Vcv- Lod t C0.. (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: YESX 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 Color r 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 121�A ❑ B DAIRY PROGRAM (2000) ❑ 6rade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit _ CUPA ❑ gazardous Materials Business Plan(1900) Number of chemicals: �t 11aIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200}—>-Tans Generated Per Year ❑ Tered Permitting Facility—> ❑ CA(2232) ❑ CE(2233,2234,2235,2237) ❑ PBR(2231) ❑ PBR HHW(223'6) ❑ Aboveground Storage Tank Facility(AST) (2600) Number of ASTs ❑ Underground Storage Tank Program (UST)(2300)Use USTA 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 HousinalLabor 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-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) ❑ P.,oultry Farm--Maximum number of birds ❑ Kennel TATTOO.BODY PIERCING.PERMANENT COSMETIC PROGRAM (4100) ❑ 4ody Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) .❑ Body Art Facility-Single Use(4120) ❑ >ody Art Facility-Sterilization (4121) [3 Body Art Temp Event Co-ord(4130) El Body Art-Temp Event Mobile Facility:;(4131) LIQUID WASTE PROGRAM(4200) ❑ TA"T Pumper VehicleRegistration# License# Capacity Vehi� ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units R SOLID WASTE PROGRAM(4400) n(�n(` ❑ Landfill 11Transfer Station ElAgfCannery Waste Site 11Sludgea SiteN�omm ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfi(/'W%En'^L 1 ❑ Refuse Vehicles w of units) ❑ Dum stars>20 Cu Emaup S p yd 1#orun'Rs) ❑ Farm/Rangh`��eantipSite 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 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue ADDlicatlon Form ` EMEOTIFICATION FOR THIs FACILITY AND/OR PROGRAM CONTACT PERSON RGENCY NDay Ph Z01-Z51-9993 Night Ph 701�Z�j)—r-f�/7� PROGRAM M T FEE ❑ SUrchar`�Ia FE 13 Other FEE INSPECTOR# PERMITVAU1 O t0 �( Z 11 Food Handler ❑ Check# AMOUNT PAID Date 1 .1,V L( INVOICE#31-011q7 ❑ Gash REVIEWED BY ACCOUNTING OFFICE Date ZO 4/23TI3 MASTERFILE RECO INFORMATION PINK 1/23/i3 1 1 6 3 3 D I z . f