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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Prom at Existing Facility ew EH P ram ari New F citit Facility ID ? Program Record ID cif Facility Address RLj gS33O (Please check the appropriate description and specify size, numbe f units an ertinent in ormation.) 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 0 Retail Market----Square footage X410 0 ❑ 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 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 ❑ 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) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Fa ilityS ogle Use(4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-T p nt Mobile Fac''t 4131) LIQUID WASTE PROGRAM(4200) 1 ❑ Pumper Vehicle Registration# License# Capacity e# Vehic' 11 Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets umber of its SOLID WASTE PROGRAM (4400) v ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ S ud lAsh i ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility A Landfill t ❑ Refuse Vehicles (4 of Units) ❑ Dumpsters>20 cu yd (a 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 ,i �U H 1111�(11N(� /�/{�_ Day Ph 707-1-1&- 1±_ Night Ph PROGRAM ELEMENT FEE iO� — ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMIT VALID ' 1S t0 5 �j ❑ Food Ha dler ❑ Check# AMOUNT PAID Date 7: INVOICE# ❑ Cash R=- I=%=D B1' ACCOUNTING OFFICE ate »E-01-034 { STERFILE RECORD INFORMATION PINK 1;23113 �j�t-'� t . �"I t kk .24 .lrf v