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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM Facility ID .1-795-7),..— Program Record ID Facility Address 2e1 CD k-Vi et:it/1yr 1/V1 IA/ CA4---1 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES El No 0 Commissary 0 Dry storage only 0 with Food Preparation :Wending Machines Number of Units Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only NMobile Food Vehicle --Make Vehicle Type - Color Registration # License # ,k--I `,-)( 1 1--i S',-<1- Sticker # Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # CI Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand Special Event---Dates of operation from to CI CFO 0 A El B New EH Program at Existing Facility El New EH Procram and New Facility -PkAs-"- 2-3 DAIRY PROGRAM (2000) Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit CUPA CI Hazardous Materials Business Plan (1900) Number of chemicals: Li CalARP Program CI Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility Hazardous Waste Generator (2200) >-Tons Generated Per Year Tiered Permitting Facility > 0 CA (2232) CI CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 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) CI Hotel/Motel Number of Units 0 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 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site Abandoned HW Site Li non-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site CI Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility 0 Pool 0 Spa CI Out of Service Pool/Spa CI Natural Bathing Area VECTOR CONTROL PROGRAM (4000) Poultry Farm Maximum number of birds CI Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) CI Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) CI Pumper Vehicle Registration # License # Capacity Vehicle # Pumper Yard El Package Treatment Plant 0 Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) Landfill CI Transfer Station Li Ag/Cannery Waste Site Cl Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility Refuse Vehicles (# of Units) Li Dumpsters > 20 cu yd (# of Units) MEDICAL WASTE PROGRAM (4500) rve„ Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0.44iVit d Hauler' CI Transfer Station CI Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 4\0 > 6 4-46t2os JO/4n PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form liEd N,VIROw AIL /m Outv, EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM t "IQE 7' lr Ph -T-kt) t 1 S--510.2Night Ph -'.77(0,=1,,z1;14., o Surchar e FE 0 Other FEE to .2-0 20 CI Food Handler Date INvoicE # ACCOUNTING OFFICE Date / 48-02-034 eotfltr 1 0 m-ra 1/23/13 MASTERFILE litCOR INFORMATION PINK Sludge/A4Site CI CIA Land Fa rm/RikjettritAlr CONTACT PERSON WI n PROGRAM ELEPAENT 07'7 FEE INSPECTOR # S 3 -2- PERMIT VALID Check #15 iPt" AMOUNT PAID Cash REVIEWED BY ( Darek