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1 • � SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RF YcMFNT MASTERFILE RECORD INFORMATION FORM �` VE " ❑New EH Program at ExistingFacllit ❑New EH Program and New Facllit D O Facllit ID Z� Program Record ID g SqN M,4 p ?Q?3 Facility Address � n&N (oul2T ENV�gQv/N (Please check the appropriate description and specify size number of units and pertinent information.) N�gC7- R�%1 CpUN FOOD PROGRAM(1600) N�EPgRTrqL rr ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES❑ No❑ MENr ❑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 la(I CFO kA❑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---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 ❑NPUSEP Cleanup Site ❑UIC Site ❑Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remedlation 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) ❑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 ❑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 ❑ 11-60 ❑>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 XRi 1/ I U Day Ph 02 —3019 Night Ph & — PROGRAM E EMENT D FEE ❑Surcharg FE ❑Other FEE INSPECTOR# t, AR t PERMIT VALID S I L t0 ( ❑Food Handler ❑Check# AMOUNT PAID Date INVOICE# ❑Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 1,23113