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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 Program and New Facility <br />Facility ID '11_0(5275-5-7 Program Record ID -P2os--Li-g2ss- <br />Square Footage / <br />0 with Food Preparation <br />El w/Meat Market only 0 Multiple <br /> Vehicle Type <br />Registration # License # Sticker # <br />El 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 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />El Grade A Dairy <br />CU PA <br />CI Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />CI Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />CI Hazardous Waste Generator (2200) >- Tons Generated Per Year <br />Tiered Permitting Facility > CI 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 />CI 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 />Environmental Assessment 0 UST-CAP Site El Local HW Cleanup Site CI NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPUSEP 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 />CI Poultry Farm------Maximum number of birds <br />0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />El Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />El Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper VehicleRegistration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ---Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill CI Transfer Station <br />O Ag/Cannery Waste Site <br />CI Waste Tire Facility GI Compost Facility O Process/Recycle Facility <br />Refuse Vehicles tit of Units) El Dumpsters > 20 cu yd or units) <br />MEDICAL WASTE PROGRAM (4500) <br />0 Primary Care CI Acute Care 0 Skilled Nursing El Large Generator <br />Transfer Station 0 Veterinary Clinic <br />0 Common Storage Facility El <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 Day Ph ..1.2 - c--)( 1:fqight Ph <br />Facility Address 1 7 r-I-H Cy_cdor\ <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />f21 Restaurant: Seating Capacity 41'Z <br />Commissary 0 Dry storage only <br />Retail Market---Square footage <br />Mobile Food Vehicle --Make <br />Food Handlers Course required: YES 0 <br />OVending Machines Number of Units <br />Departments 0 Prepackaged Goods Only <br />Color <br />No 0 <br />Sludge/ <br />CIA Lana 1.2J <br />Farm/Ranch Cleanfrsia <br />, <br />0 Small GeneratorSaildNiAed HAW <br />2-10 0 11 - 60 ti145,4116124)4h, <br />TH ENT EPA/0.444r <br />PROGRAM ELEMENT I& --:;),:-/ FEE 1'1' 72 c)--,<7 :-/ 0 El Surcharge FE <br />INSPECTOR # 6 Fel )1,-yi y PERMIT VALID O3 to a <br />riCheck # 1LQ14 ' AMOUNT PAID <br />CI Cash REVIEWED BY ACCOUNTING OFFICE <br />Date <br />d6- <br />Other FEE <br />Food Handler <br />INVOICE # E0 c7D <br />Date 3 .23 <br />48-02-034 W MASTERFILE REccfRo INFORMATION PINK 1/23/13