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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ New EH Program at Existing Facili []New EH Program and New Facility <br /> Facility ID Program Record ID <br /> Facility Address 1150 CI'1Ci4we (l U-1 Trc(e'�-I (� i9 CS377 <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 B 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# amuse _ - Sticker# <br /> ❑ Temporary Food Facility-Da ❑ Ice Plant❑ Produce Stand <br /> ❑ Special Event--Dates of open Z-)m7CFO �A 11 B <br /> � rnL �aP1�s d <br /> DAIRY PROGRAM (2000) a ''II <br /> 11 Grade A Dairy ❑ � I0 6ct 16 yJ a` '-' mber of Containers in Multi-Head Unit <br /> CUPA <br /> ❑ Hazardous Materials Busine - <br /> ❑ CalARP Program ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generato _ <br /> ❑ Tiered Permitting Facility-- 17) ❑ PBR(2231) ❑ PBR HHW(2236) <br /> ❑ Aboveground Storage Tant _ <br /> ❑ Underground Storage Tank <br /> ❑Other CUPA Program_ <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel--Number of pt Institution—Number of Units <br /> Employee Housing(2700) Use I <br /> SITE MITIGATION(2900) ITROL(3000) <br /> ❑ Environmental Assessment U USI-car anc - __ ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPLISEP 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 Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle Registration# 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(#ofunits) ❑ 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 ❑ 11 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br /> _ ,��I EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM C, <br /> CONTACT PERSON s I I tC. C I C.V Ct L G' Day Ph Z')Ci Lei lel L•L �� Night Ph Z-Oq 9I q &ZC. S <br /> PROGRAM ELEMENT_ FEEI/V [J Surcharge FEE El Other FEE <br /> INSPECTOR# ff53j--- PERMIT VALI , 2-ZCC---2772� t0 2�2-I-,-L 11 Food Handler <br /> 1:1Check# AMOUNT PAI SJ.bI.J Date 17INVOICE# <br /> ❑ Cash REVIEWED BY �, ACCOUNTING OFFICE Date <br /> MASTERFILE RECORD INFORMATION PINK <br /> 1123/13 /31677(,76 <br />