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SAN JOAQUIN COUNTY E RONMENTAL HEALTH DEPAR1 NT <br />MASTERFILE RECORD INFORMATION FORM <br />CT New EH Program at Existing Facility New EH Program and New Facility <br />Facility ID Pc) -2-6 Program Record ID ar 14Y6--1 1-/ ("(3 <br />Facility Address I ?)(-) I <br />(Please check check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />PAYMENT RECEIVE!) <br />APR <br />0 201? <br />SAN JOAQUIN COUN7Y <br />ENVIRONMENTAL. <br />HEALTH t:;13ARTMENT <br />0 Restaurant: Seating Capacity Square Footage <br />with Food <br />Food Handlers Course required: YES 0 No 0 <br />0 Commissary 0 Dry storage only CT Preparation 0Vending Machines Number of Units <br />0 Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />0 Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />CT Mobile Food Prep Unit-- Make Type 7‘.( -Vehicle Color <br />Registration # 6-712 1.2_1z 7 S 701-1 af:License # 7A15-61(.1 Sticker # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />to 0 Ice Plant 0 Produce Stand <br />to 0CF0 DAIDB <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 />CT CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) > Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) CT CE (2233, 2234, 2235, 2237) 0 PBR (2231) CT 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 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 VehicleRegistration # 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 <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# or Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care <br />0 Skilled Nursing 0 Large Generator 0 <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 <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 />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (# of Units) <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />Small Generator <br />0 11 - 60 <br />0 Limited Hauler <br />0 > 60 generators <br />CONTACT PERSON COI \ Day Ph,20C-A -1i2_3(A Night Ph <br />PROGRAM ELEMENT FEE S CT Surchar e F 0 Other FEE <br />INSPECTOR # PERMIT VALI lol17 to I Sl 0 Food Handler <br />0 Check # AMOUNT PAIb 02_ 6700 Date INVOICE # <br />o Cash REVIEWED BY 4i ACCOUNTING OFFICE <br />48-02-034 <br />Date <br />MASTERFILE RECORD INFORMATION PINK <br />1/23/13