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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />1 <br />li• New EH Program at Existing Facility CINew EH Pri <br /> <br />acility_p <br />ram and New Facility <br /> <br />_ \ 1 ''rogran Record ID -VC - '14---1-5153 , , <br />l'.---'74---- 1 <br />( <br />'-}71--kA 4 , T - Ai t o CA q53-5 i ) i , ., . 7/ Facility Addrest. 1) li 5 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br /> <br />CI Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />r'Mobile Food Vehicle --Make Ca,-1 1 <br />Registration # <br />CI Mobile Food Prep Unit-- Make <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Square Footage <br />CI with Food Preparation <br />El w/Meat Market only 0 Multiple Departments CI Prepackaged Goods Only <br />Vehicle Type inat <br />License # 4-1 SC..S9 <br />Vehicle Type <br />License # <br />to 0 Ice Plant CI Produce Stand <br />Food Handlers Course required: YES 0 No Cl <br />OVending Machines Number of Units <br />Color <br />Sticker # 1(000 <br />Color <br />Sticker # <br />Special Event---Dates of operation from to CI CFO CI A 0 B <br />DAIRY PROGRAM (2000) <br />CI 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 />CI CalARP Program CI Program 1 Facility CI Program 2 Facility <br /> CI Program 3 Facility <br />CI Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility > CI CA (2232) 0 CE (2233, 2234, 2235, 2237) CI PBR (2231) El 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 />CI Other CUPA Program <br />HOUSING PROGRAM (2400) <br />CI 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 CI UST-CAP Site 0 Local HW Cleanup Site El NPL/SEP Cleanup Site 0 UIC Site <br />CI Abandoned HW Site El 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 <br /> 0 Spa <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br /> <br />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) CI Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper VehicleRegistration # <br />Pumper Yard <br />MEDICAL WASTE PROGRAM (4500) <br />PUBLIC WATER SYSTEM PR GRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />Transfer Station 0 Veterinary Clinic <br />CI Small Generator pi* ek CI Primary Care CI Acute Care CI Skilled Nursing CI Large Generator <br />0 Common Storage Facility 0 2 - 10 0 11 -60 ill.-Tptc24AveN pry <br />A <br />EMEGEIcY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />33•i) SO) --10J5' CONTACT PERSON k C( c. kl Day Ph (7 c,7) - /0.9C/Night Ph <br />0 Out of Service Pool/Spa 0 Natural Bathing Area <br />License # Capacity Vehicle # <br />SOLID WASTE PROGRAM <br />Landfill <br />Waste Tire Facility <br />CI Refuse Vehicles (8 of <br />(4400) <br />CI Transfer Station <br />CI Compost Facility <br />Units) <br />CI Package Treatment Plant <br />El Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 9 0 CU yd (tt of Units) <br />CI Chemical Toilets ----Number of Units <br />El ilY47"6 <br />Sludge/As <br />10.. <br />lartCg.ii <br />CI CIA Landfill! Site VED <br />El Farm/RanaDlepn4,ip Site <br />SAN 2019 <br />PROGRAM ELEMENT I ICD . <br />INSPECTOR # <br />12 Check # <br />Cash <br />t4SS <br />48-02-034 <br />REVIEWED BY <br />AMOUNT PAID <br />PERMIT VALID <br />FEE 2-• - <br />?-2 <br />q/171/1 9 • <br />CI Surcharge FEE <br />to 3( iiq • <br />Date ) 11 <br />r <br />Other FEE <br />Food Handler <br />INVOICE <br />Date <br />MASTERFILE RECORD INFORMATION PINK <br />ACCOUNTING OFFICE <br />1/23/13