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-SAN-JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />/ MASTERFILE RECORD INFORMATION FORM <br />d New EH Program at Existing Facility Clew EH Program and New Facilit PAYMr <br />E" <br />Facility ID L�oj2 —L2 Program Record ID �jQ� Z,5 (3 ' Eeci;veo <br />FacilityAddress,<',�5 50 N Loibcan iA�u cfro lc�n ca4 '?52-005 MAR <br />(Please check the appropriate description and specify size, number of units and pertinent information.) s 202? <br />FOOD PROGRAM (1600) JCKQ(gN CO <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course re ui I�dfEN <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units EFgR1MENT <br />❑ Retail Market --Square footage <br />❑ w/Meat Market only <br />❑ Mobile Food Vehicle—Make <br />Vehicle Type <br />Registration # <br />License #_ <br />❑ Mobile Food Prep Unit-- Make <br />Vehicle Type _ <br />Registration # <br />License # <br />❑ Temporary Food Facility —Dates of operation <br />from <br />❑ Special Event—Dates of operation from <br />to <br />ff sl(- 4. C K-� "(&, cQd , , <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />Color <br />Sticker # <br />to <br />Color <br />Sticker # <br />❑ Ice Plant ❑ Produce Stand <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 />❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility <br />❑ Hazardous Waste Generator (2200) ---------- >-Tons Generated Per Year <br />❑ Tiered Permitting Facility ------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) <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 />❑ Program 3 Facility <br />❑ PBR (2231) ❑ PBR HHW (2236) <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel --Number of Units ❑ Jail or Exempt Institution ---Number of Units <br />Employee Housing (2700) Use Employee Housino/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-NPL/SEP 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 />❑ 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 (413 1) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration# <br />❑ Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />License # <br />❑ Package Treatment Plant <br />Capacity Vehicle # <br />❑ Chemical Toilets --Number of Units <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <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 ❑ 11 -60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON4 R a Ivilertz) j4kyiprT,5c,% Day Ph,207 Y7%36-Zc Night Ph <br />PROGRAM ELEMENT FEE -5 ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR# I Z2- PERMITVALID 13 Q22- to 5 ❑ Food Handler <br />❑ Check # AMOUNT PAID , Date ?i INVOICE # <br />ly Cash REVIEWED BY ACCOUNTING OFFICE Date <br />TION PINK <br />