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SAN JOAQUdN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existing Facility InNeW EH Program and New Facility <br />11 Facilitv ID � DD2-LI'/`-�J Program Record ID �i)?DS-4-73q I <br />Facility Address $ol WiWAvAsow Ro. 'AwrS A , CA i55i � <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle --Make <br />Vehicle Type <br />Color <br />Registration # <br />License # <br />Sticker # <br />❑ Mobile Food Prep Unit-- Make <br />Vehicle Type <br />Color <br />Registration # <br />License # <br />Sticker # <br />❑ Temporary Food Facility --Dates of operation from <br />to <br />❑ Ice Plant ❑ <br />IR,Special Event ---Dates of operation from <br />to <br />0 CFO 91 A ❑ B <br />DAIRY PROGRAM (2000) <br />Produce Stand <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 />❑ CalARP 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) ❑ PER HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A 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 Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds <br />TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # <br />❑ Pumper Yard <br />License # <br />❑ Package Treatment Plant <br />❑ Kennel <br />❑ Body Art Facility -S 20) <br />❑ Body Art-Te�ility (4131) <br />RECE <br />CapacityVe�ii le <br />E3 Chemical Toilets ----Number oiA, ��yy <br />SOLID WASTE PROGRAM (4400)�,,� �OAQU1N COUNTY <br />El Landfill El Transfer Station ❑ Ag/Cannery Waste Site Ei7Tm�w�.w <br />T <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility [RO AIriR Its <br />❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd (# of Units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 011-60 ❑ > 60 generators <br />CONTACT <br />(4600) Use PWS EHD 46-02-003 Blue Application Form <br />1011 <br />Night Ph 411 -Pt - 144 <br />PROGRAM ELEMENT I ip 0 '� FEE ❑ Surclf rge FEE El Other FEE <br />INSPECTOR# B PERMIT VALIDto I / S ❑ Food Handler <br />❑ Check # AMOUNT PAID S� Date ) 2 INVOICE #�. <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE Date L7122— 48-02-034w 3 `,G / / MASTERFILE R COR INFORMATION PINK <br />1/23/13 U D [ ! l <br />