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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility DUNew EH Program and New raclllt FAnm7ssF cf.. o.,nrd In PR0547956 Facility Addrest�— t (Please check the appropriate description and specify size, number of units and pertinent Information.) FOOD PROGRAM (1600) F Restaurant: Seating Capacity_ Square Footage t(it h V0 Food Handlers Course required: Yes ® No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending MachlnesNumber of Units ❑ Retail Market --Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle—Make Vehicle Type Color Registration # License # Sticker # ❑ Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # ❑ Temporary Food Facility --Dates of operation from to —13 Ice Plant 13Produce Stand ❑ Special Event --Dates of operation from to ❑ CFO ❑ 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 ------- > ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other COPA Program PBR (2231) ❑ PBR HHW (2236) HOUSING PROGRAM (2400) ❑ Hotel/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 TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Kennel ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper VehicleRegistraUon # License # Capacity i Y�" uri ❑ Pumper Yard ❑ Package Treatment Plant 11 Chemical Toilets --Number of I SOLID WASTE PROGRAM (4400) RECEIVED ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Slupd pelAsh Site ❑ CIS Sa922 ❑ Waste Tire Facility ❑Compost Facility ❑Process/Recycle Facility prtc9fi ❑ Refuse Vehicles (# of Unus) ❑ Dumpsters > 20 cu yd (# of Units) ❑ Farm/Ranch Cleanup Site SAN JOAQUIN COUNTY MEDICAL WASTE PROGRAM (4500) ENVIRONMENTAL ❑ Generator ❑ Small GanerifftKLil DIDOWMAINIMr ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing Large ❑ 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 Application Form '1OnTIMGAI IUN rUK i b rm4iLi i . CONTACT PERSON ayPh(:tAjnwvK r vr�nm Night Ph U61—S�'1 8 -;�%3 PROGRAM ELEMENT FEE M S -' (i ❑ Surchar0 FE / ❑ Other FEE INSPECTOR # W2ca PERMIT VALID 11 17A %Z t0 ❑ Food Handler ❑ Check# 1."i•g= AMOUNTPAID -9 "Jt Date 'I,% ��"�7 INVOICE# 369504 0 Cash nA REVIEWED 6Y ACCOUNTING OFFICE APT Date 91