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I <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARi MENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility New EH Program and New Facility <br />Facility ID F---4no.)--.2-75K3 Program ecord ID --P2(15-37. rzi <br />Facility Address '3/u' c A!, <br /> <br />Ag/Cannery Waste Site <br />El Process/Recycle Facility <br />El Dumpsters > 20 cu yd (# of Units) <br />El Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />FEB 0 4 2015 <br />Is- <br />116w <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />CI Restaurant: Seating Capacity <br />Commissary El Dry storage only <br />El Retail Market----Square footage <br />Mobile Food Vehicle --MakeG <br />Registration #C PL. g 03/ 4T3 <br />Mobile Food Prep Unit--Make c 2 o LE: 7" <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />DAIRY PROGRAM (2000) <br />El Grade A Dairy <br />CUPA <br />0 Grade B Daint 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program 0 Program I Facility 0 Program 2 Facility E Program 3 Facility <br />0 Hazardous Waste Generator (2200) > Tons Generated Per Year <br />0 Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />El Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />El 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-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 CI Out of Service Pool/Spa El 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) El Body Art Facility-Single Use (4120) <br />El Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) El Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />El Pumper VehicleRegistration # License # Capacity Vehicle # <br />El Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />El Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />El Primary Care E Acute Care 0 Skilled Nursing 0 Large Generator <br />Transfer Station El Veterinary Clinic 0 Common Storage Facility El <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />gjpERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph A; '76 '76 3V_CYNight <br />Square Footage <br />0 with Food Preparation <br /> <br /> El w/Meat Market only <br />Vehicle Type 3 ?-'-J <br />License # 5A) 5-5-3,( <br />Vehr6le Type <br />License:# 5-11)--<55- 3 `i <br />Food Handlers Course required: YES Zi" No El <br />DVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged ods Only <br />Color <br />Sticker # ,2332— <br />Color <br />Sticker # <br />to 0 Ice Plant E Produce Stand <br />to <br /> 0 CFO 0 A 0 B <br />0 Small Generator <br />2-10 El h1-60 <br />Ph 71111r1I.,IT-11::‘ I II I' IW <br />c e> <br />PROGRAM ELEMENT, IG,3 5-- FEE 0 Surcharge FE <br />INSPECTOR # PERMIT VALID c:.. l to 12- I <br />Check # t004 AMOUNT PAID Date <br />Cash REVIEWED BY <br />0 Other FEEENVIROMENTAL <br />Food Itikiialteirtj"""11 <br />VOICE # 2-(e 4/173 <br />Date <br />ta <br />ACCOUNTING OFFICE <br />48-02-034 MASTERFILE RECORD INFORMATION PINK