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SAN JOAQUIN COUNTY ENVIRONMENTAL_ HEALTH DEPARTMENT — MASTERFILE RECORD INFORMATION FORM j New EH Program at Existing Facility _ T New EH Pro ram and New Facility Facility ID f�D 2 O Program Record ID I _ 3 --- , Facility Address 46 L CP 1Rt D 1 Av(L , MuU NTA ►N U Sr` cA,nth 35 (Please check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) /' ❑ Restaurant: Sealing Capacity Squaw Fuulaqu Food Handlers Course required: Yes P No ❑ ❑ Commissary WDiy storage only IJKwith Food Preparation ❑Vending Machines Number of Units ❑ Retail Market----Squire footage _._.._____._. ❑ w/Meat Market only ❑ MUlliple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make_ Vehicle Type__— Color Registration 1/ _ License Il Sticker 11 ❑ Mobile Food Prep Unit--Make ----_- Vehicle Type _ Color_ Registration f► _ _ _ License ff Sticker It ❑ Temporary Food Facility--Dates of operation from__.-_ to __ - ❑ Ice Plant❑ Produce Stand El 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 Multi-Head Unit CUPA ❑ Hazardous Materials Business Plan(1900) Number of chemicals: ❑ CaIARP 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 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-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Rernediation Site RECREATIONAL HEALTH PROGRAM(3600) Nurnberof Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out Of Service Pool/Spa ❑ Natural 13afW VECTOR CONTROL PROGRAM(4000) r'►l(�V� `GI D El Farm-------Maximum number-of birds !________ ❑ KiiEeICEI v E TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) (� ❑ Body Art Practitioner Reg(4110) El Mechanical DSPS Notification(4115) El Body Art Facility-Single QVAAA 2Z23 ❑ Body Art Facility-Sterilization(4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile FaOc(� �►f�TY LIQUID WASTE PROGRAM(4200) SAN JV ROUNMENTpa-NT pEpARTME ❑ Pumper VehicleRegistration tt License It -..- Capacity -- e( _...__-_ ❑ 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(it of units). _ ❑ Duntpslers> 20 cu yd u+of u:i•! . ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) El Primary Care El Acute Care ❑ Skilled Nursing ❑ Large Generator El 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 Foirn EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON lflR 1-[1(�� 83 7335 Night f'h ____...... ___ PROGRAM ELEMENT , FEE , U V ❑ Surcharge FEE El Other FEE INSPECTOR# S PERMIT VALID 1 I _ — 2 _ to�— 3�" 2 ❑ Food Handler i ❑ Check rr _AMOUNT PAID _- 14 �_ Dale �_ 3 INVOICE=It ✓ �/ V ❑ Cash Rcvit:wi:o iiY : ,+Nnrac;Oi,ua_ Date ��jj ////��//,�,, 22 I - - -- -- MA5TERFILF'J C(7RO IN FORMA'rIOD�NK •i0.02-034 tR3/13 COf\-F I -4O 3` 2- 02-