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M. New EH Program at Existing Facility MNew EH Program and New Facility <br />Facility ID 64) Program Record ID F <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility Address LiO1 --Lrn p;k. l/t) -0 C 1Y, 6' Lc\ I CA (//Si91.0 <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 CI No 0 <br />CI Commissary Cl Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />CI Retail Market----Square footage El w/Meat Market only 0 Multiple Departments CI Prepackaged Goods Only <br />CI Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />CI Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />CI Temporary Food Facility --Dates of operation from to CI Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />CI Grade A Dairy <br />CUPA <br />Cl Grade B Dairy CI Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />2 Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program 0 Program 1 Facility CI Program 2 Facility 0 Program 3 Facility <br />CI Hazardous Waste Generator (2200) > Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 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 />CI Other CUPA Program <br />HOUSING PROGRAM (2400) <br />CI Hotel/Motel Number of Units 0 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 />Environmental Assessment CI UST-CAP Site 0 Local HW Cleanup Site CI NPL/SEP Cleanup Site 0 UIC Site <br />CI Abandoned HW Site El non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility CI Pool CI Spa 0 Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />CI Poultry Farm Maximum number of birds CI Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper Vehicle Registration # License # Capacity Vehicle # <br />CI Pumper Yard CI Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill 0 Transfer Station El Ag/Cannery Waste Site 0 Sludge/Ash Site <br />CI Waste Tire Facility 0 Compost Facility CI Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (# of Units) El Dumpsters > 20 cu yd (# of Units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care CI Acute Care CI Skilled Nursing CI Large Generator 0 Small Generator CI Limited Hauler <br />CI Transfer Station CI Veterinary Clinic CI Common Storage Facility 0 2 - 10 CI 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 ELEM NT /q4-1) FEE 4 0 Surcharge FEE 30 CI Other FEE <br />INSPECTOR # PERMIT VALID to CI Food Handler <br />CI Check # AMOUNT PAID 1 Date -';h1 ) 24) INVOICE # <br />CI Cash REVIEWED BY ACCOUNTING OFFICE Date 3/II 0-4) <br />48-02-034 <br /> <br />MASTERFILE RECORD INFORMATION PINK <br />CONTACT PERSON <br />1/23/13