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SAN JOAQUIN COUNTY E IRONMENTAL HEALTH DEPAR" 'ENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility "dew EH Program and New Facility <br />Facility ID 0 6)-01S- Program Record ID /2-(D5C13735. <br />Facility Address gq.D -1-wl A\te- SCAvl a.)\11-iti '91 Li OLP Lo <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />El Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES El No 0 <br />0 Commissary 0 Dry storage only El with Food Preparation OVending Machines Number of Units <br />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 # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # <br /> License # Sticker # <br />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 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />LI CalARP Program 0 Program 1 Facility 0 Program 2 Facility D Program 3 Facility <br />Hazardous Waste Generator (2200) > Tons Generated Per Year <br />El Tiered Permitting Facility > 0 CA (2232) El CE (2233, 2234, 2235, 2237) D 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 />El 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 LI UST-CAP Site El Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site LI 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 0 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) El Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />El Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art- Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) PAYtAlvicn <br />Pumper Vehicle Registration # License # CapaRECEiv 1.0.• Vehicle # <br />El Pumper Yard El Package Treatment Plant El Chemical Toiletsc—Nurritogit f Units <br />SOLID WASTE PROGRAM (4400) SEP 2 -831 <br />0 Landfill CI Transfer Station LI Ag/Cannery Waste Site un4 c0141S1udge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle FacilitySAT4 unn3VotimegGN-411A Landfill Site <br />Refuse Vehicles (# of units) Dumpsters > 20 cu yd of Jai 1!1)El'ARIM arm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care El Acute Care 0 Skilled Nursing D Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station El Veterinary Clinic El Common Storage Facility El 2 - 10 0 11 - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Forn1 <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAM ELEMENT k6D\ FEE 00 <br />INSPECTOR # gers7 PERMIT VALID GI, <br />Ei Check # AMOUNT PAID <br />'ash REVIEWED BY (NIA <br />48-02-034 MASTERFILE RECORI INFORMATION PINK <br />ACCOUNTING OFFICE <br />LI Surcha ge F EQ El Other FEE <br />to 0 Food Handler <br />Date • Ea lir, INVOICE# 315 <br />ra Date /45) <br />1/23/13