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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />IVIASTERFILE RECORD INFORMATION FORM I <br />0 New EH Program at Existing Facility AiNew EH Program and New Facili y I _ <br />Jacility ID D2 1—.1;'&' Program Record ID p et.„0 sii s"2" <br />Facility Address 5bLi el L.3 5ch4 le Rot * 107 1 rrAcl Q 95 5 7 7 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No El <br />ID Commissary 0 Dry storage only El with Food Preparation ElVending Machines Number of Units <br />El Retail Market----Square footage 0 w/Meat Market only El Multiple Departments El Prepackaged Goods Only <br />El Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />El Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />El Temporary Food Facility --Dates of operation from to 1=3 Ice Plant. El Produce Stand <br />El Special Event---Dates of operation from to EICF0 DADB <br />DAIRY PROGRAM (2000) <br />El Grade A Dairy LI Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />CI Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program El Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) Tons Generated Per Year <br />El Tiered Permitting Facility > El CA (2232) El CE (2233. 2234 2235. 2237) El PBR i2231) El PBR HHW (2236) <br />''Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />ED Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />GI Other CUPA Program <br />HOUSING PROGRAM (2400) <br />El Hotel/Motel Number of Units El 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 />El Environmental Assessment 0 UST-CAP Site El Local HW Cleanup Site 0 NPL/SEP Cleanup Site 1:7 Uic Site <br />El Abandoned HW Site El non-NPL/SEP Cleanup Site. El RWOCB Cleanup Site El Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ID Pool El Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />El Poultry Farm Maximum number of birds El Kennel <br />TATTOO, BODY PIERCING. PERMANENT COSMETIC PROGRAM (4100) <br />El Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification 14115) DI Body Art Facility-Single Use (41201 <br />Body Art Facility-Sterilization (4121) El Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility 14131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # Capacity Vehicle # <br />El Pumper Yard 0 Package Treatment Plant El Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />DI Landfill El Transfer Station El Ag/Cannery Waste Site 0 Sludge/Ash Site <br />El Waste Tire Facility El Compost Facility El Process/Recycle Facility El CIA Landfill Site <br />El Refuse Vehicles p-r. izit units) El Dumpsters > 20 cu yd i# of Units) CI Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />El Primary Care El Acute Care CI Skilled Nursing El Large Generator 0 Small Generator El Limited Hauler <br />Transfer Station 0 Veterinary Clinic El Common Storage Facility El 2 - 10 1:1 ii - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph Night Ph <br />PROGRAM ELEMENT FEE Surcharge FEE g-40 El Other FEE <br />INSPECTOR # PERMIT VALID to El Food Handler <br />Date 1 i.,-41/g0 1/6 INVOICE•33 6g <br />CONTACT PERSON <br />E Check # AMOUNT PAID <br />18-C.2-0;74 <br />0 Cash REVIEV!ED BY ‘1:›araa CR ACCOUNTING OFFICE Date4 I <br /> <br />tv STERFILE .D INFORMATION PM. 1 2 ,3 1Z