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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM Facility ID 04170 21- io 2-1 Facility Address 51 PIVT"T e-P-30,Ni PrV C::',\ ts-4 i---7, ,illt-')-Iti4( N 4i 614 , (F) ? .) I' (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) 0 Restaurant: Seating Capacity Square Footage Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units Retail Market--Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only Mobile Food Vehicle --Make Vehicle Type Color Registration # License # Sticker # Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand Special Event—Dates of operation from to 0 CFO 0 A 0 B DAIRY PROGRAM (2000) Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit CUPA Hazardous Materials Business Plan (1900) Number of chemicals: CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility Hazardous Waste Generator (2200) ->- Tons Generated Per Year Tiered Permitting Facility ------> CI CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) Aboveground Storage Tank Facility (AST) (2800) Number of ASTs Underground Storage Tank Program (UST) (2300) Use UST A and B forms Other CUPA Program HOUSING PROGRAM (2400) Hotel/Motel ----Number of Units 0 Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPLJSEP Cleanup Site 0 UIC Site Abandoned HW Site 0 non-NPLJSEP 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 El Natural Bathing Area VECTOR CONTROL PROGRAM (4000) Poultry Farm-----Maximum number of birds 0 Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) 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) Pumper Vehicle Registration If License If Capacity Vehicle # Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets --Number of Units SOLID WASTE PROGRAM (4400) Landfill ID Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site Waste Tire Facility 0 Compost Facility ID Process/Recycle Facility 0 CIA Landfill Site Refuse Vehicles (# of Units) El Dumpsters > 20 cu yd (to of Units) 0 Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler 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 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON 4tAitx- lv is: Day Ph If 0 b" >VI G. .ci-e( Night Ph V? 6/ Uri New EH Program at Existing Facilit aNew EH Pro ram and New Faci it Program Record ID 12/Co ..61.5 3 Food Handlers Course required: YES 0 No 0 PROGRAM ELEMENT k \OU6 FEE %k1:0 0 Other FEE CI Food Handler INvolcE# Date 0 Surcharae FEE INSPECTOR # t("\\'\OV e'S PERMIT VALID Lk • 1-1 • 2 to Lt 130' 29 - El Check # \e--) AMOUNT PAID Date Cash REVIEWED BY ACCOUNTING OFFICE 48-02-034 1/23/13 ASTERFILE CORD INFORMATION PINK