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-SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Proaram at Existinq Facilitv ❑New <br />11 Facility ID 7-h002/,>57'jProaram Record ID f/<0,54 /Jo7 II <br />Facility Address 35'50 N - W i ISOfJ 1..9/Mf <br />Si1'TI <br />(Please check the appropriate description and specify size, number of units <br />and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage <br />Food Handlers Course required: Yes ❑ Nox, <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑Vending Machines Number of Units <br />❑ Retail Market ---Square footage ❑ w/Meat Market only <br />❑ Multiple Departments Xprepackaged Goods Only <br />❑ Mobile Food Vehicle—Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />❑ Mobile Food Prep Unit-- Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />❑ Temporary Food Facility —Dates of operation from <br />to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to <br />❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200)--- ------ >-Tons Generated Per Year <br />❑ Tiered Permitting Facility ------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PBR HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use USTA and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel—Number of Units ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housinq/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm ------Maximum number of birds_ <br />❑ Spa ❑ Out of Service Poo(/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) P�� <br />❑ Pumper Vehicle Registration# License # Capacity pt�. <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets —Number 6PdratsE���B <br />SOLID WASTE PROGRAM (4400) R <br />❑ Landfill 11 Transfer Station 11Ag/Cannery Waste Site ❑`SI9d jeFAj02re <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility SAaj@I b ndfill Site <br />11Refuse Vehicles (#of units) ❑ Dumpsters > 20 cu yd (#of units) ��NgQ1�{�NNanup Site <br />MEDICAL WASTE PROGRAM (4500) HEALTH OEPgRTMENT <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 -10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />�CONTACTPERSON ghtPhQ •� g' �q12(I� <br />PROGRAM ELEMENT I US"I FEE V 15L -.?- ❑ Surcharae FEE, ❑ Other FEE <br />INSPECTOR # <br />❑ Check # _ <br />Cash <br />48-02-034 <br />1/23113 <br />PERMIT VAL <br />AMOUNT PAID <br />REVIEWED BY <br />to <br />5 5 Date <br />ACCOUNTING OFFICE <br />❑ Food Handler <br />INVOICE # <br />Date /.2/7/2 <br />