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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT — <br /> MASTERFILE RECORD INFORMATION FORM <br /> 0 New EH Program at Existing Facility ❑New EH Pr r in and New Facillt <br /> Facility IDProgram Record ID <br /> Facility Address <br /> (Please check the appropriale description and specify size,number of units and ertinent information.) <br /> FOOR PROGRAM(1600) b <br /> aRestaurant: Seating Capacity�SSquare Foolage7 63o SF' • Food Handlers Course required: YeaZlNo ❑ <br /> 0 Commissary 0 Dry storage only 0 with Food Preparation ❑Vending Machines Number of Units <br /> 0 Retail Market—Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br /> 0 Mobile Food Vehicle-Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> O Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> 0 Temporary Food Facility-Dates of operation from to 0 Ice Plant 0 Produce Stand <br /> 0 Special Event—Dates of operation from to Z3 CFO 0 A 0 B <br /> DAIRY PROGRAM(2000) <br /> 0 Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUPA <br /> 0 Hazardous Materials Business Plan(1900) Numberof chemicals: <br /> 0 CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br /> 0 Hazardous Waste Generator(2200)--->-Tons Generated Per Year <br /> 0 Tiered Permitting Facility—> 0 CA(2232) 0 CE(2233,2234,2235,2237) 0 PER(2231) 0 PER HHW(2236) <br /> 0 Aboveground Storage Tank Facility(AST)(2800) Number of ASTs <br /> 0 Underground Storage Tank Program(UST)(2300)Use USIA and B forms <br /> O Other CUPA Program <br /> HOUSING PROGRAM(2400) <br /> 0 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 /> 0 Environmental Assessment 0 UST-CAP Site O Local HW Cleanup Site 0 NPUSEP Cleanup Site 0 UIC Site <br /> 0 Abandoned HW Site 0 non-NPUSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality RemeQ[t "Sit@-, <br /> RECREATIONAL HEALTH PROGRAM(3600) RECEIVED <br /> Number of Pools/Spas at Facility _ 0 Pool 0 Spa D Out of Service Pool/Spa 0 Naturaap n�J <br /> Area <br /> VECTOR CONTROL PROGRAM(4000) 61 f 2022 <br /> 0 Poultry Farm--Maximum number of birds 0 Kennel <br /> t'.Y JC.�iLli 11 q- Y <br /> TATTOO BOGY PIERCING PERMANENT COSMETIC PROGRAM(4100) r°°�����•+cnI, <br /> :u rni <br /> 1•i.�1LiI1 I.....11i14F r.1 <br /> 0 Body Art Practitioner Reg(4 110) 0 Mechanical DSPS Notification(4115) 0 Body Art FacilitySingle Use(4120) <br /> O Body Art Facility-Sterilization(4121) 0 Body Art Temp Event Coord(4130) 0 Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> 0 Pumper Vehicle Registration# License# Capacity Vehicle# <br /> 0 Pumper Yard 0 Package Treatment Plant 0 Chemical Tollets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> 0 Landfill 0 Transfer Station 0 AglCannery Waste Site 0 Sludge/Ash Site <br /> 0 Waste Tire Facility 0 Compost Facility 0 ProcessiRecycle Facility 0 CIA Landfill Site <br /> 0 Refuse Vehicles f#oi uoisl_ 0 Dumpsters>20 cu yd(#or Ujr•„ ❑ FarmiRanch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> 0 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br /> 0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2-10 011-60 0 >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Appl(catlon Form <br /> EN ENCY NOTIFICATION FOR THIS FA CITY NOIOR PR GR ^� <br /> ,CONTACT PERSON Day P ig Ph ?LA+ b�2�� <br /> PROGRAM ELEMENT -9 FEE 0 Surch#r'I F E 0 Other FEE <br /> INSPECTOR# - PERMIT VALID )(.; ) 7", 2 2— f0 -'i���I � 2-?7 ❑ Food Handler <br /> 0 Check# f(t— AMOUNTPAID Date I G �I rat- ��Z� VOICE# )1 7 <br /> 0 Cash REVIEWED BY ACCOUNTING OFFICE Date ) �� IL <br /> 4342434 'I 4�✓ as MASTERFILE RECORD INFO TI N PINH <br /> +123113 J� 151 )_) `� <br />