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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />&Kew EH Program and New Facility <br />Program Record ID <br />El New EH Program at Existing Facility <br />Facility ID 5.16 ° <br />PERMIT VALID <br />12 Check # VI C7 AMOUNT PAID <br />CI Cash REVIEWED BY 5g <br />48-02-034 <br />1/23/13 <br />0 Surcharge FE <br />dlf7p2- tO 3 6 - Date <br />ACCOUNTING OFFICE <br />617a 1 1Z--1 MASTERFILE RE ORD IN ORMATION PINK <br />INSPECTOR # <br />PROGRAM ELERA...ENT I (0 C 3 FEE <br />6..„ <br />3 0 Other FEE <br />ID Food Handler <br />DatP lI <br />Facility Address (56 (2_ Pluro(13 -J\vc <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />CI Restaurant: Seating Capacity Square Footage <br />Commissary 0 Dry storage only 0 with Food Preparation :Wending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only CI Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # Sticker # <br />Registration # Sticker # <br />CI Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to 12(CF0 Of A El B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <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 CI Program 2 Facility CI Program 3 Facility <br />Hazardous Waste Generator (2200) >- Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) CI 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 />CI 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 CI UST-CAP Site 0 Local HW Cleanup Site CI NPL/SEP Cleanup Site 0 UIC Site <br />0 Abandoned HW Site El non-NPL/SEP Cleanup Site CI RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool CI Spa CI Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper VehicleRegistration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />CI 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 CI Skilled Nursing CI Large Generator <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility CI <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 />600 --3-t; 6 o CONTACT PERSON #311L0101 P C Day Ph 41 6 (f- 6 3 660 Night 1311,7 6q- <br />Food Handlers Course required: YES 0 No 0 <br />CI Mobile Food Prep Unit-- Make Color <br />License # <br />Vehicle Type <br />License # <br />0 Body Art Facility-Single UsbA <br />0 Body Art-Temp Event Mobiren i REC VE u <br /> License # <br />CI Package Treatment Plant <br /> <br />Vehiclpitirmo Capacity <br />CI Chemical Toilets ----Number of Units 11 22 <br /> <br />El Ag/Cannery Waste Site <br />0 Process/Recycle Facility <br />CI Dumpsters > 20 cu yd of units) <br /> <br />S <br />i iikNts JOAQUNI mNECNOTUANLTY <br />CI SI udge <br />0 CIA LalriefillINAEPARTMENT <br />0 Farm/Ranch Cleanup Site <br /> <br />0 Small Generator 0 Limited Hauler <br />2-10 CI 11 - 60 0 >60 generators