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SAN JOAQUIN COUNTY I IRONMENTAL HEALTH DEPAR ENT <br />MASTERFILE RECORD INFORMATION FORM <br />,Z(New EH Program at Existing Facility ONew EH Program and New Facility <br />Facility ID (---/-1 0 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />t clg 0 S <br />FOOD PROGRAM (1600) , <br />Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES El No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation <br />0 Multiple Departments 0 Prepackaged\ o•s iods Only <br /> <br />El Retail Market----Square footage 0 w/Meat Market only <br /> <br />cp-4obile Food Vehicle --Make' r(\ Vehicle Type 'VG\ tefl 10 Color . AA <br />Registration # 1 1;9S 7 in S's iiionZOoLicense # (oz.) e 3 9 LI Sticker # <br />Mobile Food Prep Unit-- Mak6 Vehicle Type Color <br />Sticker # <br />DAIRY PROGRAM (2000) <br />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 <br /> CI Program 3 Facility <br />Hazardous Waste Generator (2200) > Tons Generated Per Year <br />LI PER (2231) 0 PBR HHW (2236) Tiered Permitting Facility > LI CA (2232) LI CE (2233, 2234, 2235, 2237) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Cl 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 LI Local HW Cleanup Site 0 NPL/SEP Cleanup Site CI UIC Site <br />Abandoned HW Site LI 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 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />CI Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 1=1 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 VehicleRegistration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill LI Transfer Station LI Ag/Cannery Waste Site 0 Sludge/Ash Site <br />El Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (# of Units) Li Dumpsters > 20 cu yd (# of Units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care CI Acute Care 0 Skilled Nursing 0 Large Generator CI Small Generator 0 Limited Hauler <br />CI Transfer Station 0 Veterinary Clinic CI Common Storage Facility 0 2-10 Li 11 - 60 0 >60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />E GENCY NOTIFICATION FOR THIS FACILITY A D R.PTC,VM <br />CONTACT PERSON Day Ph, — Night Ph <br />e F E 0 Other FEE <br />LiFood Handler <br />INVOICE # _277L3 <br />Cash ACCOUNTING OFFICE <br />Facility Address 171A0A <br />Program Record ID II-4-'0 5-4r /tt q <br />PA Vmeivr tk-cEiverf <br />/144 )/ <br />Sd <br /> 2 1 2015 jo <br />A ()UN COUNry ENViROME-NTAL DE-PARTmc-Afr <br />OVending Machines Number of Units <br />Registration # License # <br />Temporary Food Facility --Dates of operation from to Li Ice Plant 1=1 Produce Stand <br />Special Event---Dates of operation from to 0CF0 0A1=1B <br />tr-02-034 <br />PROGRAM ELEMENT <br />INSPECTOR # <br />CI Check # <br />REVIEWED BY ri <br />FEE <br /> PERMIT VALID <br />AMOUNT PAID <br />0 Surchar <br />to <br />Date ,3 <br />Date ,,,;7C,//_S <br />57 MASTERFILE REC RD INFORMATION PINK <br />1/23/13