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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑New EH Prooram and New Facility ID rftOfz(o%-77D Program Record ID -rWAIv47R9% 11 .Facility Address a 14 WWTRy CA. LK\6 I D SU;r: l�- (Please check the appropriate description and specify size, number of units andpertinent information.) FOOD PROGRAM (1600) []Restaurant: Seating Capacity. Square Footage Food Handlers Course required: 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 Color Registration # License # Sticker # ❑ Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # ❑ Temporary Food Facility --Dates of operation from to ❑ Ice PlantI*Ar uc ��e Stand ElSpecial Event ... Dates of operation from to ❑ CFO El El /M DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Mufti- a®�y/��I I CUPA `S JO Z�� ❑ Hazardous Materials Business Plan (1900) Number of chemicals: N�E(Tvj O CO N ❑ Hazardous Waste Generator (22El CaIARP Program❑00)rogram> TonstGenerated❑r Per Year ogram 2 Facility ❑Program 3 Facility MOEpyR AANry iv ❑ Tiered Permitting Facility -... ---> ❑ CA (2232) ❑ CE (2233, 22341 2235, 2237) ❑ PER (2231) ❑ PBR HHW (2236) El Aboveground Storage Tank Facility (AST) (2800) Number of ASTS El Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ Hotel/Motel------Number of Units 11 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 El Abandoned HW Site El non-NPL/SEP Cleanup Site 1:1RWQCB Cleanup Site 11 Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility L1 Pool 11 Spa 11 Out of Service Pool/Spa El Natural Bathing Area VECTOR CONTROL PROGRAM (4000) r"! Poultry F ❑ arm -------Maximum number of birds TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Kennel ody Art Practitioner Reg (4110) 11 Mechanical DSPS Notification (4115) ❑Body PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION Art Facility -Single Use (4120) Body Art Facility -Sterilization (4121) El Body Art Temp Event Comord (4130) ❑Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) L1 Pumper Vehicle Registration # License # Capacity Vehicle # El Pumper Yard El Package Treatment Plant 11 Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) El Landfill El Transfer Station ElAg/Cannery Waste Site ❑ Sludge/Ash Site 11 Waste Tire Facility 11 Compost Facility ElProcess/Recycle Facility 11 CIA Landfill Site El Refuse Vehicles p of units) ElDumpsters > 20 cu yd (# of units) 11Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) El Primary Care El Acute Care 1:1 Skilled Nursing El Large Generator ❑ Small Generator El Limited Hauler El Transfer Station 11 Veterinary Clinic El Common Storage Facility L12 -10 11 11-60 El> 60 generators FOR THIS FACILITY AND/OR PROGRAM OC CONTACT PERSON L115 w CF¢tJAN DFz Day Ph �9% GIMP `a� GI Night Ph PROGRAMS FEE INSPECTOR# PERMIT VALID A� ❑ Check,#AMOUNT PAID m 11 S, _ Date OFFICE t0 _ El Other FE E _ ❑Food Hand//ler INVOICE# .3b.5� Date 1 % Z� 4302-034�� MASTERFILE RECORD INFORMATION PINK 1/23/73 _�,Y