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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />�I Facility ID QAC-nX7359 Prooram Record ID f &g -t!%974 <br />,facility Addres.l`� Flo UNP -.V' 111 s�rym qj�j <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 ❑ 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 ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to li.:Cl CFO. XA ❑.. B I <br />v - <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 />❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility <br />❑ Hazardous Waste Generator (2200) ------- -->-Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) <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 />❑ Program 3 Facility <br />❑ PBR (2231) ❑ PBR HHW (2236) <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Emp/ovee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP 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 <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Kennel <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Ajr1V4gfW Use (4120) <br />[]Body Art Facility -Sterilization (4121) []Body Art Temp Event Co-ord (4130) ❑ Body /�✓6rwt6ivtbobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) GI�CCC��YYCCLLJJ <br />❑ Pumper Vehicle Registration # License # Capacity CSp I 9� hicle # <br />El Pumper Yard ❑ Package Treatment Plant 13 Chemical Toilets---NNuum�be of0 <br />SOLID WASTE PROGRAM (4400) SAN JOAQUIN COUNTY <br />ENVIRON <br />11Landfill ❑Transfer Station ❑ Ag/Cannery Waste Site HEALTH ON a/Ash Site <br />DEI <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility Indfill Site <br />❑ Refuse Vehicles (# of Units) ❑ Dumpsters > 20 cu yd (#of units) ❑ 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 />Use PWS EHD 46-02-003 Blue Application Form <br />e <br />,sem-�r��mr rnr.!•r. - esMI7�:�PX#jAE= <br />PROGRAM ELEMENT FEE p ❑ Surch�far a FEE ❑ Other FEE <br />INSPECTOR # ML),f n PERMIT VALID I 2Z t0 ` ,3D Z2— ❑ Food Handler <br />11Check # AMOUNT PAID 18 6 Date Q ;LZ INVOICE # --137-7 <br />0 Cash REVIEWED ACCOUNTING OFFICE Date W917172- <br />1/23113 <br />217 72 <br />1/23/13 <br />