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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM Lew EH Program at Existing Facility ❑ New EH Program and New Facility 11 Facility ID U0 ;73Sd Pro ram Record ID kosA 7 � Facility Address 45 i z /! Cltirc�/v iZiD . /t4 4 ,vTc../7 A , 14 � i in < ( 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 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 Plant ❑ Produce Stand ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000 ) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in MultkHead 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 ----Number of Units Employee Housing (2700 ) Use Employee HousinalLabor 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 ) Q Body Art Practitioner Reg (411 o) ❑ 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) pp ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/As7—iAM��T ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Land��I l� ❑ Refuse Vehicles I# or Units) ❑ Dumpsters > 20 cu yd (# or Units) ❑ Farm/Ranch CTI?�Mt of MEDICAL WASTE PROGRAM (4500 ) FP 9 ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator Limited flal?? ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 - 60 OW ors PUBLIC WATER SYSTEM PROGRAM ( 4600 ) Use PWS EHD 46-02-003 Blue Application Form H&UTMd M NaAL O/yIvry EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM _ EP�TMNr CONTACT PERSON YD / Roy i ; 77%77 7< \j Day Ph 15 , c ) 7SS - Ac2Sy Night Ph <3 PROGRAM ELEMENT 4110 FEE IS ❑ Surchar a FEE ❑ Other FEE INSPECTOR # �I `dS3 PERMITVALID 9 to � 3 ❑ Food Handler Vheck # AMOUNT PAID : Date _p` 2 Z INVOICE # 37, SZ- ash ` REVIEWED BY ACCOUNTING OFFICE ( Date q 27 lZ- 48-02-034 MASTERFILE RECOR INFORMATION PINK 1 /23/13