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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility ❑New EH Program and New Faclt� <br />Facility ID �-4Q�a7741 Program Record ID 1" DVfn 5 L J <br />Facility Address '�D 7 A" m,,/,' <br />(Please check the appropriate description and specify size, number of units and pertinent Information ) <br />FOOD PROGRAM (1600) <br />RFq Y�IF <br />At,/ UN '?0 <br />0,4 Q <br />,yF4T�NM co?3 <br />FpgR�Tq� Ty <br />❑ Restaurant. Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ NT <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Mobile Food Prep Unit– Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Temporary Food Facility --Dates of operation from to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to ❑ CFO ❑ A 118 <br />DAIRY PROGRAM (2000) <br />[I Grade A Dairy ❑ Grade 8 Dairy El Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous , laterials Business Plan (1900) Number of chemicals: <br />{ ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />I� ❑ Hazardous Waste Generator (2200) -------->-Tons Generated Per Year <br />�l ❑ Tiered Permitting Facility --> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑PBR (2231) ❑ PBR HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />J ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel -----Number of Units ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />�j ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds_ <br />TATTOO. BODY IERCING PERMANENT COSMETIC PROGRAM (4100) <br />218ody Art Practitioner Reg (4110) ❑ Mechanical DSPS NOdficatlon (4115) ❑ Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # License # Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets —Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (x of Units) ❑ Dumpsters > 20 cu yd (9 of Units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic Q Common Storage Facility ❑ 2 - 10 ❑ 11-60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application Form <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />CONTACT PERSON <br />Day Ph <br />PROGRAM ELEMENT `I I I O FEE +t / ❑ St <br />INSPECTOR # PERMIT VALID to <br />❑ Check # _- AMOUNT PAID S •I� Date <br />❑ Cash REVIEWED BY <br />46.02-034 n <br />!23113 <br />ACCOUNTING OFFICE <br />/6X23b69-� <br />14L) Night Ph <br />❑ Other FEE _ <br />❑ Food Handler <br />INVOICE # 372 <br />Date 7, —6 <br />PINK <br />