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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility ONew EH Program and New Facility <br />Facility ID 1400.2:75-76 <br /> <br />Program Record ID <br />Facility Address \\*,-- )( A-0L- t")--)a A- Q e , s 31 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br />Registration # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to laCF0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CU PA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) > -Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 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 />LI Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units 0 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 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Facility-Single Use (4120). Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) <br />O Body Art-Temp EverRA*MEAlity (4131) Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) <br />RECEIVED LIQUID WASTE PROGRAM (4200) <br /> <br />Capacity Vehicle # Pumper Vehicle Registration # License # <br />0 Chemical Toilets 0 Package Treatment Plant <br />Ag/Cannery Waste Site <br /> , 04.41 NiAUNAL:re <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (# of Units) <br /> 01:1 FaIrm--1441/RadnlicilhiSlICIedjlaEnNuTp Site <br />11 - 60 0 > 60 generators <br />Sc 1. 3.5-77 <br />License # <br />Square Footage <br />0 with Food Preparation <br />0 w/Meat Market only <br /> Vehicle Type <br />Food Handlers Course required: YES„0/ No 0 <br />OVending Machines Nuber of Units <br />0 Multiple Departments. IV' Prepackaged Goods Only <br /> Color <br />Sticker # <br />0 Kennel <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 <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 30-neLd 6-t Day Ph 5• T.Y'7-'35 ---/7 Night Ph <br />----Number of l)AtkR 1192023 <br />PROGRAM ELEMENT k,(Ce C-; FEE <br />INSPECTOR # '''))-1 C 'S PERMIT VALID <br />Check #\/ 1,(--t-i- AMOUNT PAID <br />Cash REVIEWED BY <br />48-02-034 <br /> <br />AOCE5-7:)? <br />ACCOUNTING OFFIC <br />MASTERFILE R CO D INFORMATION PINK <br />Other FEE <br />Food Handler <br />INVOICE # 7- /..3 a av <br />Date