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SAN JOAQUIN COUNTY E. RONMENTAL HEALTH DEPAR1ONT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility ONew EH Program and New Facility <br />Program Record ID RECP ' r -xts---(4231 -iv o <br />Amp <br />(Please check the appropriate description and specify size, number of units and pertinent information.) SqA, , 1 2019 "dal <br />FOOD PROGRAM (1600) <br />Food Handlers Course Restaurant: Seating Capacity Square Footage ./Z/N-PROQIptj/N-COIA4h. requirem-f/fut A .1sjittir <br />Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />0 Retail Market----Square footage 0 with Meat Market only 0 Multiple DepartmentsEl Prepackaged Goods Only <br />Registration # License # Sticker # IFR,Q <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />Color 0 Mobile Food Prep Unit Make Vehicle Type <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant <br />0 Special Event Dates of operation from to 0 Produce Stand <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA 0 Hazardous Materials Program (1900) 0 Hazardous Materials Business Plan (1920, 1921) <br />Hazardous Waste Program (2200) <br />Hazardous Waste Generator Tons Generated Per Year 0 Recycle/Exempt System (2299) <br />CRT Offsite Handlers (2218) 0 Silver Only (2222) 0 Appliance Recyclers (2217) <br />Tiered Permitting Facility 0 Conditionally Authorized (CA) 0 Conditionally Exempt (CE) <br />0 Permit-By-Rule Fixed Unit 0 Permit-By-Rule Household Haz Waste <br />Aboveground Storage Tank Facility (AST) (2390) Number of AST <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <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-NPLJSEP 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 />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) 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 Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (tt of Units) Dumpsters > 20 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 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />Facility ID F-AO0 I g <br />Facility Address <br />PROGRAM ELEMENT /635- FEE#-.2-37. 97) 0 Surcharg FE 0 Other FEE <br />INSPECTOR # 7K,83- PERMIT VALID //J1' to 2 __?( 0 Food Handler <br />0 Check # AMOUNT PAID ,23-7. () Date <br />Cash REVIEWED BY ACCOUNTING OFFICE <br />711 <br />—1.44 <br />INVOICE # <br />Date <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />8/21/12