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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />)4 New EH Program at Existing Facility <br />0New EH Program and New Facility <br />Facility ID F4 to) 9S.,1 Program Record ID Pk05+51€2-- <br />Facility Address icd.5 .1 Murphy 'ZA, cki:)c)n La c'f -- Le (c, <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />CI Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation CIVending Machines Number of Units <br />0 Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br /> <br />Registration # License # Sticker # <br />CI Mobile Food Prep Unit-- Make Vehicle Type Color <br /> <br />Registration # License # Sticker # <br />CI Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand .*) CI Special Event—Dates of operation from to CI CFO CIAO B <br />44 16 I S75cd <br />DAIRY PROGRAM (2000) <br />LI Grade A Dairy D Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />\CyPA <br />RHazardous Materials Business Plan (1900) Number of chemicals: 1 <br />Li CalARP Program CI Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Li Hazardous Waste Generator (2200) > Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) Li CE (2233, 2234, 2235, 2237) 0 PBR (2231) CI PBR HHW (2236) <br />CI Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />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 CI 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 />CI Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site Li UIC Site <br />Li Abandoned HW Site Li non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site CI Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa Li Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />El Poultry Farm Maximum number of birds C7 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) Li Body Art Facility-Single Use (4120) <br />CI Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # Capacity Vehicle # <br />CI Pumper Yard CI Package Treatment Plant 1=1 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill CI Transfer Station Li Ag/Cannery Waste Site 0 Sludge/Ash Site <br />El Waste Tire Facility CI Compost Facility CI Process/Recycle Facility CI CIA Landfill Site <br />Li Refuse Vehicles (# of Units) 0 Dumpsters > 20 cu yd of Units) CI Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care 0 Acute Care CI Skilled Nursing Li Large Generator 0 Small Generator CI Limited Hauler <br />CI Transfer Station 0 Veterinary Clinic CI Common Storage Facility Li 2- 10 0 11 -60 Li >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 />CONTACT PERSON Day Ph Night Ph <br />PROGRAM ELEMENT FEE ,IS FEE CI Other FEE <br /> <br />INSPECTOR # 1i3C, 9 PERMIT VALID to El Food Handler <br />0 Check # AMOUNT PAID Date 1 )-7 P-0 INVOICE # <br />CI Cash REVIEWED BY Sork-6 ACCOUNTING OFFICE 145 Date 31170-0 <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />1/2313