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SAN JOAQUIN COUNTY E ,RONMENTAL HEALTH DEPAR" :NT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility <br />:New EH Program and New Facility <br />Facility ID 4902--`1-i& Program Record ID Fkz.15 az) <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 />ID Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) CI 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 CI Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site El non-NPLJSEP Cleanup Site CI RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool El Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds CI Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) Cl 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 # <br />CI Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill 0 Transfer Station El Ag/Cannery Waste Site 0 Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />CI Refuse Vehicles (# of Units) El Dumpsters > 90 cu yd (# of Units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator CI Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 El > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />S 69-677 )-Z.Vight Ph <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph <br /> <br />License # Capacity Vehicle # <br /> <br />0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />PROGRAM ELEMENT , C : .'H FEE .-E- < -c. vi.-.. rv9 I <br />, U INSPECTOR # PERMIT VALID ") / ^7. <br />0 Check # AMOUNT PAID <br />CI Cash REVIEWED E(Y <br />0 Surcharge FEE 0 Other FEE <br />to 1t 7 0 Food Handler <br />Date INvoicE# <br />Date 7 ACCOUNTING OFFICE <br />Facility Address 3 1 ao Reβ€ž.vvi e v"? 6'β€˜ At/e _ssotc β€˜,7 -te> <br />(Please check the appropriate description and <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity Square Footage Ifr-Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />License # <br />Vehicle Type <br />Registration # License # Sticker # ti S if C <br />El Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to CI CFO CI A 0 B <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 />48-02-034 <br />MASTERFILE RECORD INFORMATION PINK <br />specify size, number of units and pertinent information.) <br />Registration # <br />)6-Mobile Food Prep Unit-- Make <br />Food Handlers Course required: YES CI No 0 <br />CIVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />1/23/13