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MASTERFILE REC•RD NFORMATION PINK /36,q71440 <br />CONTACT PERSON <br />PROGRAM ELEMENT I FEE <br />INSPECTOR# PERMIT VALID <br />El Check # V/4,39,--• AMOUNT PAI • 171 <br />Cash REVIEWED BY <br />48-02-034 <br />.1/23/13 <br />Em RGE NOTIFI <br />CUAda (r1.0 <br />f <br />ATION FOR THIS FACIL TY ND/OR PROGRAM <br />Day Ph Zthigagiv Night Ph 2 0C/ — c, <br />El Surchame FEE <br />to <br />Date <br />lE <br />El Other FEE <br />El Food Handler <br />INvoicE# <br />Date /0 n5 Ii ACCOUNTING OFFICE <br />SAN JOAQUIN COUNTY EN) DNMENTAL HEALTH DEPARTIV <br />MASTERFILE RECORD INFORMATION FORM <br /> New EH Program and New Facility oc r 09 2018 <br />1 3F I AN h., Pro ram Record ID 1 41blb 8 <br />ENviRoN L'OUNTy HEALTH DEpM,,ENTAL <br />(Please check the appropriate description and specify size, number of units and pertinent information.) friRTmENT <br />FOOD PROGRAM (1600) <br />Ci Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES El No El <br />Commissary El Dry storage only El with Food Preparation OVending Machines Number of Units <br />El Retail Market----Square footage 0 w/Meat Market only El Multiple Departments El Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />Nt4Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to El Ice Plant 0 Produce Stand <br />El Special Event---Dates of operation from to El CFO 0 A Cl B <br />'El New EH Program at Existing Facility <br />460 249L3 Facility ID <br />Facility Address 9So 2,11 <br />PANENT <br />REcEiveD <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />0 Grade B Dairy ID Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program El Program 1 Facility 0 Program 2 Facility El Program 3 Facility <br />CI Hazardous Waste Generator (2200) > Tons Generated Per Year <br />El Tiered Permitting Facility > El CA (2232) El CE (2233, 2234, 2235, 2237) El PBR (2231) El PBR HHW (2236) <br />El Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />El Other CUPA Program <br />HOUSING PROGRAM (2400) <br />El Hotel/Motel Number of Units El 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 />El Environmental Assessment CI UST-CAP Site 1:1 Local HW Cleanup Site CI NPL/SEP Cleanup Site Cl UIC Site <br />El 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 El Pool Cl Spa ri Out of Service Pool/Spa El Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />El Poultry Farm Maximum number of birds El Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />El Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) El Body Art Facility-Single Use (4120) <br />El Body Art Facility-Sterilization (4121) El Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />El Pumper Vehicle Registration # <br />Pumper Yard El Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />El Landfill El Transfer Station El Ag/Cannery Waste Site <br />El Waste Tire Facility El Compost Facility l:=1 Process/Recycle Facility <br />El Refuse Vehicles (# of units) El Dumpsters > 20 cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />El Primary Care El Acute Care in Skilled Nursing El Large Generator <br />El Transfer Station El Veterinary Clinic El Common Storage Facility 0 2 - 10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />License # Capacity Vehicle # <br />El Chemical Toilets ----Number of Units <br />El Sludge/Ash Site <br />El CIA Landfill Site <br />D Farm/Ranch Cleanup Site <br />l Small Generator :1 Limited Hauler <br />El 11 - 60 Cl >60 generators