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SAN JOAQUIN COUNTY E 'RONMENTAL HEALTH DEPART .NT <br />MASTERFILE RECORD INFORMATION FORM <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 />ew EH Program at Existing Facility <br />Facility ID OD02•"1 (p Program Record ID <br />Facility Address Address 2900 P hard/r7 iUck (.4 ici-vvi iq 52 <br />(Please check the appropriate descri tion and specify size/number d i f <br />FOOD PROGRAM (1600) <br />ONew EH Program and New Facility <br />PAYMENT <br />RECEIVED <br />AU id 4 2017 <br />OAQUIN COUNTY <br />NVIRONMEIVTAL o units an pertinentn ormat on.) HEALTH DEPARTMENT <br />0 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YE421\ No 0 <br />0 Commissary 0 Dry storage only <br />0 Retail Market----Square footage <br />0 with Food Preparation <br />0 w/Meat Market only <br />0Vending Machines Number of <br />0 Multiple Departments 0 Prepackaged <br />Units <br />Goods Only <br />0 Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />,a\Mobile Food Prep Unit-- Make Vehicle Type Color --> Registration # License # Sticker # 5 9 <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event—Dates of operation from to 0 CFO 0 A 0 B <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 />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) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 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 Vehicle Registration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <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 <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 L victsecy V an keA4 rc <br />0 Food Handler <br />)7 <br />INFORMATION PINK <br />1/23/13 <br /> <br />License # Capacity Vehicle # <br /> <br />0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />0 11 - 60 0 > 60 generators <br />PROGRAM ELEMENT 1 FEE -- ) ' 7 CC 0 Surcharge FEE 0 Other FEE <br />,- <br />INSPECTOR # 's ' I( /...j PERMIT VALID / Li I I -7 to /2 /. i 1 C-2 <br />Check # ") ‘-i. (") AMOUNT PAID 9 -s"? — Date INVOICE # , cl <br />0 Cash <br />48-02-034 MASTERFILE REC/Ro <br />REVIEWED BY .i, _ ACCOUNTING OFFICE Date 7 <br />Day Ph 14-0-b-ZoS-2,o;L( Night Ph O3-2o4