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4' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑Now EH Program at Exist' Facilit ❑New EH Pro ram and New Facility Facility ID Program Record ID (p Facility Address..U2 2 �iGCCI Ch t'�� 1.GVl� tl�i�2�, Ct (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 repaired: Yes ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units❑ Retail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Registration# Color License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Special Event---Dates of operation from ❑ Ice Plant❑ Produce Stand to Cl ❑ 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: ❑ CalARP 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) ❑ PBR(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 ❑Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution A----I i4er of Units Employee Housing(2700)Use Employee Housing/Labor Camn Application Form EEtV SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(300gECE1VED ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/ C �, ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ae Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) nh 1o�ouiN cou"�v Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/ H OEM"N�ru ©`'`Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm-------Maximum number of birds ❑ Kennel TATTOO,BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ 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 Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----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 y ❑ CIA Landfill Site ❑ Refuse Vehicles M 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 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Fonn EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON-Ka - Da Ph r/ Y Night Ph PROGRAM ELEME T U S FEE b ❑ Surch rge FE ❑ Other FEE I INSPECTOR# PERMIT VALID t0 Z ❑ Food Handler b ❑ Check# V -A AMOUNT PAID — Date INVOICE# I ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date �, 4&02-034 1/23/13 I �3 / MASTERFILE RECORD INFORMATION PINK ,l C 10