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. <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />O New EH Program at Existing Facility kleyy_EH Program and New Facili <br />Facility IDX41171) 2'5" Program Record ID <br />Facility Address Ilaa--1 E.. figkri- M de. Rd 3itck--Inn Cr( ss—a) <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES El No El <br />0 Commissary CI Dry storage only 0 with Food Preparation 0Vending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only CI Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />0 Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to El Ice Plant CI Produce Stand <br />CI Special Event---Dates of operation from to 0 CFO 0 A0 B <br />DAIRY PROGRAM (2000) <br />CI Grade A Dairy D Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />CI Hazardous Materials Business Plan 11900) Number of chemicals: <br />0 CalARP Program 0 Program 1 Facility 0 Program 2 Facility El Program 3 Facility <br />Hazardous Waste Generator (2200) = Tons Generated Per Yea< S 4-00 <br />CI Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234. 2235, 2237) CI PBR (22311 El PBR HHW 12236) <br />D 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 El Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application FOI711 <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />CI Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site CI U c Site <br />CI Abandoned HW Site El non-NPL/SEP Cleanup Site CI RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool CI Spa CI Out of Service Pool/Spa CI 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 />Cl Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification 14115) E Body Art Facility-Single Use (4120) <br />CI Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard CI Package Treatment Plant El Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill ID Transfer Station CI Ag/Cannery Waste Site 0 Sludge/Ash Site <br />0 Waste Tire Facility 0 Compost Facility CI Process/Recycle Facility CI CIA Landfill Site <br />CI Refuse Vehicles (# of UnIIS El Dumpsters > 20 cu yd ,# of Units) CI Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care El Acute Care D Skilled Nursing 0 Large Generator 0 Small Generator CI Limited Hauler <br />El Transfer Station 0 Veterinary Clinic CI Common Storage Facility CI 2 - 10 0 11 - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application F01171 <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAM ELEMENT ;)-)-DO FEE 219 <br />INSPECTOR # 6)1 Isa,6 PERMIT VALID to CI Food Handler <br />CI Check # AMOUNT PAID II2L -Date 3/1 t 0-0 thiNvorcE# 33 <br />CI Cash ACCOUN1ING OFFICE <br />-18-02-C34 MCSTERFILE R_CORD INFopmf,TIoN <br />l;l'sgti-rcharge FEE, Jig --- CI Other FEE <br />Date 2,71 2 p