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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />and New <br />r�'IZ' �i moi` r %'7alTi'�rS1l� <br />Facility Address 101(; I) I1ur ( n n V -V.( n t n 101/ ( A i W <br />(Please check the appropriate description and specify size, number of units and pertinent Information.) <br />FOOD PROGRAM (1600) <br />RRCF QED <br />SqN OCT 18 2012 <br />NEOAQUy /NCT <br />ELTH ERMNygr <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 />_ <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 />❑ Special Event --Dates of operation from <br />to <br />❑ CFO ❑ 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 />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200)------> -Tons Generated Per Year <br />❑ Tiered Permitting Facility—-> [ICA(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 LISTA and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ HotellMotel---Number of Units ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Houslno2abor 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-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remedlatlon Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Poot spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -----Maximum number of birds ❑ 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 Coord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # _ License # Capacity Vehicle # _ <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets --Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ AglCannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (# or 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 4602-003 Blue Application Form ( t, 1 <br />�Ih��� ,, EMERGENCY NOTIFICATION FOR HIIS� Ph(Nig <br />AND/CR PROGRAM <br />Night Ph ( O I M / 7,j% -516Y <br />CONTACT PERSON <br />PROGRAM ELEMENT �% FE X37 � ❑ Surd FE ❑ Other FEE _ <br />INSPECTOR#� PERmrr VALID /a IS 22 to 1 31 ❑ Food Handler <br />❑ Check# s..b— AMOUNT PAID Date / / ZZ INVOICE# 3 6 <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 6 9 <br />48-02-034 ,/ X �j MASTERFILE RECORD INF <br />/� <br />1123/13 n.� -1 IS -1547 S-6 <br />