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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RFS N�ENr <br /> MASTERFILE RECORD INFORMATION FORM E/V/ 6 <br /> ❑ New EH Program at Existing Facility ONew EH Program and New Facility SEP <br /> FacilityID �� Pro ram Record ID SA/V JO 5 202, <br /> Facility ckMILEROAD, <br /> "EATNPMDE <br /> (Please check the appropriate description ad specify sZe, f unis and pertinent inmRTEo <br /> F ODrC P (11600)Sea <br /> Q9 Restaurant: Seating Capacity 60 Square Footage 2500 SFT Food Handlers Course required: YEs Ca No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market—Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle-Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit-Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility-Dates of operation from to - 11 Ice Plant 11Produce Stand <br /> ElSpecial Event--Dates of operation from to 13CFO ❑A❑ B <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit _ <br /> CUPA <br /> ❑ Hazardous Materials Business Plan(1900) Number of chemicals: <br /> ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator(2200)---->-Tons Generated Per Year <br /> ❑ Tiered Permitting Facility--> ❑CA(2232) ❑ CE(2233,2234,2235,2237) ❑ PBR(2231) ❑ 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 ❑ Jail or Exempt Institution---Number of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Camp Ann/ication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number of birds ❑ Kennel <br /> TATTOO.BODY PIERCING.PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art Facility-Single Use(4120) <br /> ❑ Body Art Facility-Sterilization(4121) ❑ Body Art Temp Event Coord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper VehicleRegistration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd w of units) ❑ Fann/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 1:111 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue ADDlicaugn Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON ARMANDO ADI LA Day Ph 510 508 8934 Night Ph 510 508 8934 <br /> PROGRAM ELEMENT FEE o.Q 11 Surch4raFE 11 Other FEE <br /> INSPECTOR# PERMITVALD n -Zto <br /> 3 2� ❑ Food Handler /� <br /> ❑ Check# AMOUNT PAID Date INVOICE#� 0 <br /> 11 Cash REVIEWED BY ACCOUNTING OFFICE Date c <br /> 122 <br /> 48-02-034 MASTERFILE RECOPID INFORMATION PINK <br /> 1/23/13 <br />