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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br /> <br />D New EH Program at Existing Facility New EH Program and New Facility <br />1 Facility ID OAT 61gLf Program Record ID -Pg.e5L-1531-7 <br />Facility Address atICt LIceshif.e_, 54- )1Actri4“,ot CD, q5577 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />El Restaurant: Seating Capacity <br />El Commissary 0 Dry storage only 0 <br />El Retail Market--Square footage <br />Mobile Food Vehicle --Make <br />Registration # License # <br />El Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to El Ice Plant 1:1 Produce Stand ".) 0 Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />CI Grade A Dairy <br />CUPA <br />D Grade B Dairy El Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />El Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program 0 Program 1 Facility 0 Program 2 Facility El Program 3 Facility Ajazardous Waste Generator (2200) > Tons Generated Per Year < e to,/ <br />Tiered Permitting Facility > 0 CA (2232) CI CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR NNW (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 El Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Fonn <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />CI Environmental Assessment CI UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site El U iC Site <br />Abandoned HW Site El non-NPL/SEP Cleanup Site El RWQCB Cleanup Site El 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 />ED Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) El Mechanical DSPS Notification (4115) El Body Art Facility-Single Use (4120) <br />0 Body Art Facility-Sterilization (4121) ID Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # <br />El Pumper Yard 0 Package Treatment Plant Cl Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill El Transfer Station El Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility El Process/Recycle Facility <br />Refuse Vehicles (# of Units) El Dumpsters > 20 Cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator El Limited Hauler <br />0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility El 2 - 10 El 11 - 60 El > 60 generators <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 /> Day Ph Night Ph <br />Square Footage <br />with Food Preparation <br />El w/Meat Market only <br /> Vehicle Type <br />Food Handlers Course required: YES El No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />El Kennel <br />Capacity Vehicle # <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />CONTACT PERSON <br />PROGRAM ELEMENT D-R•26 FEE 2- cf,c1 - <br />INSPECTOR # R PERMIT VALID <br />Check # AMOUNT PAT - Date 4/00 <br />Cash REVIEWED BY \t(2)54(1A ACCOUNTING OFFICE <br />0 Other FEE <br />0 Food Handler <br />INvoicE# .311-ta-3 <br />Date <br />2"-§lfrcharge FEE <br />to <br />48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23M