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SAN JOAQUIN COUNTY ElIONMENTAL HEALTH DEPARTS. MASTERFILE RECORD INFORMATION FORM Facility ID 2.47 Program Record ID ?0,s"--1-35-7 CI New EH Program at Existing Facility DNew EH Program and New Facility EMERGENCY ts9QTIFICATI9N FOR THIS FAC CONTACT PERSON kAC,,- IG1 r) Day Ph PROGRAM ELEMENT P'-1; FEE :43 7 INSPECTOR # PERMIT VALID Check # AMOUNT PAID Cash REVIEWED BY ITY AND/OR PROGRAM 016 - RjOilght Ph (20) \-1O- CI Food Handler INVOICE # 3,9928 Date 2- 3 to on Date ACCOUNTING OFFICE 4 El e FE CI Other FEE El Ag/Cannery Waste Site Process/Recycle Facility Dumpsters > 20 cu yd (# of units) Sludge/Ash Site CIA Landfill Site Farm/Ranch Cleanup Site Facility Address g) 3 S c &vvi -k--0 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) 0 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES :ommissary CI Dry storage only 0 with Food Preparation OVending Machines Number of Units CI Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only CI Mobile Food Vehicle --Make Vehicle Type Color Registration # License It Sticker # Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker It CI Temporary Food Facility --Dates of operation from to CI Ice Plant 0 Produce Stand CI Special Event---Dates of operation from to CI CFO 0 A 0 B DAIRY PROGRAM (2000) CI Grade A Dairy CUPA CI Grade B Dairy CI Milk Dispenser-Number of Containers in Multi-Head Unit CI Hazardous Materials Business Plan (1900) Number of chemicals: El CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility CI Hazardous Waste Generator (2200) > Tons Generated Per Year CI Tiered Permitting Facility > CI CA (2232) CI CE (2233, 2234, 2235, 2237) CI PBR (2231) 0 PBR HHW (2236) Cl Aboveground Storage Tank Facility (AST) (2800) Number of ASTs CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms Other CUPA Program HOUSING PROGRAM (2400) CI Hotel/Motel Number of Units CI Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) CI Environmental Assessment 0 UST-CAP Site CI Local HW Cleanup Site CI NPL/SEP Cleanup Site CI UIC Site Cl Abandoned HW Site El non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility CI Pool CI Spa 0 Out of Service Pool/Spa CI Natural Bathing Area VECTOR CONTROL PROGRAM (4000) Poultry Farm Maximum number of birds CI Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) 0 Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) CI Pumper VehicleRegistration It Pumper Yard SOLID WASTE PROGRAM (4400) CI Landfill 0 Transfer Station CI Waste Tire Facility El Compost Facility CI Refuse Vehicles (# of Units) MEDICAL WASTE PROGRAM (4500) CI Primary Care 0 Acute Care 0 Skilled Nursing CI Large Generator 0 Small Generator 0 Limited Hauler Transfer Station CI Veterinary Clinic CI Common Storage Facility 0 2 - 10 0 11 - 60 0 >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form 4-O2-O34 MASTERFILE RECORD NFORMATION PINK License # Capacity Vehicle # CI Package Treatment Plant 0 Chemical Toilets ----Number of Units 1/23/13