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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT u MASTERFILE RECORD INFORMATION FORM � Facility ID QAC( 2[`j (� Program Record ID Facility Address 0jSZ0S (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with FOQd Preparation []Vending Machines Nu,�ber of Units Detail Market ---Square footage ? oO`C.4t w/Meat Market only 11 Multiple Departments F Prepackaged Goods Only ❑ Mobile Food Vehicle —Make Vehicle Type Color Registration # License #_ ❑ Mobile Food Prep Unit-- Make Vehicle Type Registration # License #_ ❑ Temporary Food Facility --Dates of operation from ❑ Special Event ---Dates of operation from to DAIRY PROGRAM (2000) to Sticker # Color Sticker # ❑ Ice Plant ❑ Produce Stand 1:1 CFO ❑A❑B ❑ 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 CUPA 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 ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) p v ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) 11 Body Art FacilitySiPA AIRMT ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Evj Ve i1& (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration # License # Capacity JANN114#20.23 ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets --Number ofUnits a4N JOAQUJN COUNTY SOLID WASTE PROGRAM (4400) r, -sEC ❑ Landfill 11Transfer Station ❑ Ag/Cannery Waste Site fkF NT ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (#of Units) ❑ Dumpsters > 20 cu yd (# of units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 - 6p ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02.003 Blue Application Form % EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON L biD -f Yo.m..,�, ., Day Ph 3��0 i�(>T iXX Night Ph , D� PROGRAMELEMENT /6'/. 5 FEE ❑ SurCF jge EE 11 Other FEE INSPECTOR# J�S PERMITVALID 1. G�(_�^ Z t0 (! I L ❑ Food Handler ❑ heck # AMOUNT PAID 7 .� Date ) ( iro L INVOICE # Z.,3 ash REVIEWEDBY ACCOUNTING OFFICE Date V 8-02-034 MASTERFILE RECOM INFORMATION PINK 1/23/13