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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑New EH Program at Existing Facility ❑New EH Pr r m and New Facility Facility ID � W U—1 �, i `f, Program Record ID Facility Address Inform �(S 36 S (Piease check the appropriale description and specify size,number of units and ertinent a0on.) FOODPROGRAM(1600) L�.Restaurant: Sealing Capacity--�4 SSquare Foofage26�o SF • Food Handlers Course required: YeaZlNo ❑ ❑ Commissary 0 Dry storage only ❑with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market—Square footage ❑ w/Meat Market only ❑Multiple Departments 0 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 ❑ Ice Plant 0 Produce Stand ❑ Special Event—Dates of operation from to Z3 CFO 0 A 0 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) ❑ P13R(2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST)(2800) Number of ASTs ❑Underground Storage Tank Program(UST)(2300)Use UST A and B forms 0 Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel-1,umber 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 0 UST-CAP Site 0 Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality RemoQ[ Igo Sit@-T RECREATIONAL HEALTH PROGRAM(3600) RECEIVED Number of Pools/Spas at Facility _ ❑Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Naturaap n�J Area VECTOR CONTROL PROGRAM(4000) 61 f 2022 ❑ Poultry Farm--Maximum number of birds ❑ Kennel icnrnuv� vnnr TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) 1•f..1LTII IIL1Al<1lAF i.l ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art FacilitySingle Use(4120) 0 Body Art Facility-Sterilization(4121) ❑Body Art Temp Event Coord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper VehicleRegistratlon# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant 0 Chemical Tollets—Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#oi unnsi_ ❑ Dumpsters>20 cu yd(#or uoa„ ❑ FarmlRanch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator 0 Limited Hauler ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility 0 2-10 ❑ 11-60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form _ EN ENCY NOTIFICATION FOR THIS FA LITY NolI R PR GR ^� '®r CONTACT PERSON ^.e C, Day P fright Ph ?lam+ b�2� PROGRAM ELEMENT -� FEE ❑ Surcharge F E ❑ Other FEE INSPECTOR# - PERMIT VALID )G ) 1<.Z L t0 �'i�'_'I L>✓ 2-?% ❑ Food Hand�lJer ❑ Check# f(4-- AMOUNTPAID Dale I �� }I �-'!/-I VOICE# / "1 7 ❑ Cash REVIEWED BY ACCOUNTING OFFICE Dale ) 7� I 4g42-0a4 7, <�✓ as MASTERFILE RECORD INFO TI N PINH +rzarta - 1 S) �_� `�