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SAN JOAQUIN COUNTY EN ONMENTAL HEALTH DEPARTII, T <br />MASTERFILE RECORD INFORMATION FORM <br />"New EH Program at Existing Facility ONew EH Program and New Facility <br />Facility ID OO2.tT71 Program Record ID 11,_65-2 /2 ,72-2, <br />Facility Address 2-440 • Pc12-A00,24- W Al °4V-1‘.1 °12-0La <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 <br />CI Commissary CI Dry storage only 0 with Food Preparation 0Vending Machines Number of Units <br />CI Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />CI Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />Vehicle Type Color <br />Registration # License # '3 ‘--- 2 1 `-± a IP Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant CI Produce Stand <br />0 Special Event---Dates of operation from to 0 CFO CI A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy CI Grade B Dairy CI Milk Dispenser-Number of Containers in Multi-Head Unit <br />CU PA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />CI Hazardous Waste Generator (2200) > Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) El CE (2233, 2234, 2235, 2237) 0 PBR (2231) CI PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />El 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 />CI Environmental Assessment 0 UST-CAP Site CI Local HW Cleanup Site El NPL/SEP Cleanup Site CI UIC Site <br />CI Abandoned HW Site El non-NPL/SEP Cleanup Site CI RWQCB Cleanup Site CI Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility CI Pool 0 Spa 0 Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) CI Bo <br />CI Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill 0 Transfer Station <br />Waste Tire Facility CI Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care CI Acute Care CI Skilled Nursing 0 Large Generator 0 Small Generator CI Limited Hauler <br />Transfer Station CI 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 FOIM <br />EMV,p4,GENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON AYVNA k p Day Ph aol_iig--iipzight 41-111-7(p-2. <br />PROGRAM ELEMENT D FEE Surcha ge F E 0 Other FEE <br />INSPECTOR # g 1— PERMIT VALID VS to \2- CI Food Handler <br />Check # AMOUNT PAID -),C51? Date it/\‘''Vt INvacE# 318.06— <br />USash REVIEWED BY IV ACCOUNTING OFFICE dr_ Date /1/21 /5?' <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />1/23/13 <br />?kMobile Food Prep Unit-- Make CAAtv <br />0 Kennel <br />ility-Single Use (4120) <br />El errALk2eEvent Mobile Facility (4131) <br />License # <br />CI Package Treatment Plant <br />El Ag/Cannery Waste Site <br />CI Process/Recycle Facility <br />El Dumpsters > 20 cu yd (# of Units) <br />CI Chemical To ets *ItNumAirlits <br />Cap .\41tk # <br />:4 2 Sludge/Ash Site <br />eor 0 CIA Landfill Site <br /> 0 Farm/Ranch Cleanup Site