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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART. !NT MASTERFILE RECORD INFORMATION FORM 0 New EH Program at Existir, I Facility _ _ IIIINew EH Program and,New Facility I ..? , I Facility ID ri/14-t--' '.. ./----1 - ' " ' 1 > - - 2 _""-; Program Record ID i' i - -, r (..) - - 4 Facility Address .b1.5 Et1 0a.,4z ayrie ,S-11alveldi C4q Ct.. . . (Please check the appropriate description and specify Ain, number of units and pertinent Information.) FOOD PROGRAM (1600) 0 Restaurant: Seating Capacity Square Footage Food Handlers Course reouired: Yes a No 0 0 Commissary 0 Dry storage only 0 with Food Preparation 0VondIng Machines Number of Units 0 Retail Market—Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only 0 Mobile Food Vehicle --Make Vehicle Type Color Registration # License # Sticker # 0 Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # 0 Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand 0 Special Event—Dates of operation from to II CFO II A 0 B DAIRY PROGRAM (2000) 0 Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit CUPA 0 Hazardous Materials Business Plan (1900) Number of chemicals: o CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility Hazardous Waste Generator (2200) > -Tons Generated Per Year 0 Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) 0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs 0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms 0 Other CUPA Program HOUSING PROGRAM (2400) Hotel/Motel --Number of Units 0 Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housino/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) 0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site 0 Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality RemediatIon Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) Poultry Farm ----Maximum number of birds 0 Kennel TATTOO, BODY PIERCING‘ PERMANENT COSMETIC PROGRAM (4100) 0 Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) 0 Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) 0 Pumper VehicleRegistration # License # Capacity Vehicle # Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets --Number of Units 0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA tAPN117 D 1314:1Nti023 SOLID WASTE PROGRAM (4400) Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 SludA likt 0 Refuse Vehicles (ma units) 0 Dumpsters > 20 cu yd (11 of Units) 0 Farm/Ranch Cleanup Site ^4:0A0U114 COUNTY MEDICAL WASTE PROGRAM (4500) tROMMt NT ALti 00 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator Et E MireTHatil r 0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2- 10 0 11 -60 0 >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) use pws END 46-02-009 Blue Application Form • EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON rAt Maray Day Ph 1-041 • 1-103 • 014 13Night Ph tlY1-e.-- PROGRAM ELEMENT ; 60 co) FEE 0 Surcharge FEE 0 Other FEE INSPECTOR,/ :_tS fL PERMIT VALID I, IO / 0 Food Handler CI Check I* V I C-J1' AMOUNT PAID / Date ? -,,` INVOICE # mmTERrDatetE ilecono edFoRiaTios PWSf 0 Cash REVIEWED BY ACCOUNTING OFFICE .41) 48-02-034 1/23113