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New EH Program at Existing Facility <br />Facility ID <br /> gNew EH Program and New Facility <br />Program Record ID <br /> <br />a5-27L 033 <br />SAN JOAQUIN COUNTY El ZONMENTAL HEALTH DEPART IT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility Address r7t71-- LLftiC7 -1 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # Sticker # <br />IA Mobile Food Prep Unit-- Make-heki Vehicle Type".:-75-, ,..,,--,- ( cA) Color <br />Registration #((-(- itPi-3:4 64 c'7- <br /> <br />3 h. i 6 Ci -k-% License # e?..44t(2d- io Sticker # li!(49 `5 10-L->`-11 <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to OCF0 0A0B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />LI 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 > LI 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 WC Site <br />Abandoned HW Site 0 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 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />El Poultry Farm Maximum number of birds El 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 />0 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 />0 Landfill 0 Transfer Station 0 Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (# of units) 0 Dumpsters > 20 Cu yd (# 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 El 11 - 60 El > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />/-) <br /> <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON /. <br />„ , <br />Day Ph 2c-7 - 2 ,/ -i///// Night Ph <br />Square Footage <br />El with Food Preparation OVending Machines Number of Units <br />LI w/Meat Market only 0 Multiple Departments El Prepackaged Goods Only <br />Color <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />PROGRAM ELEMENT (o5 FEE <br />INSPECTOR # I lfW PERMIT VALID/ 720 S <br />El Check # AMOUNT PAID )()--3 • 7)2) <br />0 Cash REVIEWED BY ACCOUNTING OFFICE <br />48-02-034 <br />Other FEE <br />Food Handler <br />INvoicE# <br />Date <br />MASTERFILE RECOR6 INFORMATION PINK <br />0 Surcharge F <br />to 5 <br />Date <br />1/23/13