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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility <br /> <br />ONew EH Program and New Facilit <br /> <br />Facility ID F-4co_7s32_ Program Record ID ?RD Pi-g'25-0 <br /> <br />Facility Address 2(, 3 . t f Fe in r /1 it 51- ,.5 lo C Kt eh L A- 5'2&5' <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage g• <br />Mobile Food Vehicle --Make <br />0 w/Meat Market only <br />Vehicle Type <br />Registration # License # Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <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 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 />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-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 />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) 0 Body Art Facility-Single Use (4120) <br />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 />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 0 Transfer Station <br />o Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Dumpsters >20 cu yd (#01 Units) Refuse Vehicles (# &Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2- 10 <br />CONTACT PERSON /tQz,-..57-li '7/11 -01Ctie'. <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Nlymber of Units <br />0 Multiple Departments Prepackaged Goods Only <br />Color <br />Sticker # <br /> to 0 Ice Plant 0 Produce Stand <br />to OCF0 0A0B <br />Sludge/Ash Site <br />0 CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />Small Generator 0 Limited Hauler <br />11 - 60 <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 />Day Ph Wight Ph <br />> 60 generators <br />0 Surchar e FE <br /> th <br />27 .00 Date 17 <br />PROGRAM ELEMENT s\12\ FEE <br />INSPECTOR # PERMIT VALID <br />Check # 0,6a_.-- AMOUNT PAI <br />V\\NOPAcOUNTING 0 Cash REVIEWED BYG OFFICE . V\ <br />Other FEE <br />Food Handler <br />INVOICE # <br />Date a- .2 23 <br />48-02-034 <br />1/23/13 <br />MASTERFILE RECORD IN ORMATION PINK