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SAN JOAQUIN COUNTY E .RONMENTAL HEALTH DEPAR" INT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility ID <br />New EH Program at Existing Facility <br />0/1 <br />0New EH Program and New Facility <br />Program Record ID --FP.05-47L-1 21 <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (# of Units) <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />PAYMENT <br />RECEIVED <br />AUG 1 1 2017 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL <br />HEALTH DEPARTMENT Facility Address 76;() pio c-,i-di <br />(Please check the appropriate description and specify size, numbVr of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />P Restaurant: Seating Capacity Square Footage <br />. commissary 0 Dry storage only 0 with Food Preparation <br />..0 Retail Market----Square footage 0 w/Meat Market only <br /> <br />-, -,Mobile Food Vehicle --Make Vehicle Type <br /> <br />Registration # <br />X <br /> <br />Registration # <br />License # <br />Mobile Food Prep Unit-- Make Vehicle Type <br />License # ,..2.c= ...) H 2. <br />Temporary Food Facility --Dates of operation from to <br />Special Event---Dates of operation from to <br />Food Handlers Course required: YES No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />Sticker # <br /> 0 Ice Plant 0 Produce Stand <br />0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />0 Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) > Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />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 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 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />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 />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 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 />L--0005 1b/?y Day Ph 120 co yol W,10Night Ph .20q) 1.101-71,Do <br />PROGRAM ELEMENT FEE ,3 0 Surchar. <br />F <br /> 0 Other FEE <br />INSPECTOR # / PERMIT VALID to 1- 3 <br /> <br />_(0 Food Handler <br />Check # AMOUNT PAI 3 DO Date INVOICE # 5- 9 SI__ <br />Cashash <br />4 <br />REVIEWED BY ,_ ACCOUNTING OFFICE Date 1/ 17 <br />MASTERFILE REC RD INFORMATION PINK <br />1/23/13 <br />CONTACT PERSON <br />a ft