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S�-,-OfzsuSA\, <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT C r"O� <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility El New EH Program and New Facili <br />Facility ID L',2(9/,� Program Record IDSA{%3$� PR� <br />Facility Address 3250 W Grant Line Rd, Tracy, CA 95304 f <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />F e PRO <br />RestaGRAM (1600) <br />urant: Seating Capacity_()___Square Footage N/A Food Handlers Course required: Yes No ❑ <br />❑ Commissary ❑ Dry storage only 11 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 ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to ❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) '��11'' <br />11 Grade A Dairy El Grade B Dairy L1 Milk Dispenser -Number of Containers in Multi -H dlyN <br />CUPA ECET <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: EQ <br />❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility DFr f n <br />❑ Hazardous Waste Generator (2200) -------->-Tons Generated Per Year - r U X021 <br />❑ Tiered Permitting Facility -----> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) <br />Program "jg236) <br />11 Aboveground Storage Tank Facility ( ( 2800) Number of ASTsHHDERM❑ Underground Storage Tank (UST)(2300) Use USTA and B forms TE <br />NT <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 Application 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 <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm ------- Maximum number of birds_ <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ 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 Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # License # Capacity <br />Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ---Number <br />of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site <br />❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ CIA Landfill Site <br />❑ Refuse Vehicles p of units) ❑ Dumpsters > 20 cu yd (# of Units) <br />❑ Farm/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 112 - 10 <br />❑ 11 - 60 ❑ > 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 />CONTACT PERSON Robert Scott Tyler Dav Ph 940 295 7135 <br />Nicht Ph 940 295 7135 <br />PROGRAM ELEMENT��b\ FEE �O ❑ Surchaarge c)==. 11 Other FEE <br />INSPECTOR# UvIN�AiPERMIT VALID ���y'[�r �.7�1 to !."�/-'^ Z 11 Food Handler <br />11Check# Oma— PAMOUNTPAID 3JL/. OD Date INVOICE# <br />El Cash REVIEWED BY ACCOUNTING OFFICE Date W22124 <br />48-02-034 MASTERFILE RE ORD INFORMATION PINK <br />1/23/13 W 4 <br />