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Program Record ID - FPDSL1-S 395- <br />0, Retail Market----Square footage <br />Mobile Food Vehicle --Make rf)-1- <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />El w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Vehicle Type 1 rcA %( e r Color ye <br />License # I-4 L.1,2:. Li?, a 5- Sticker # q6,11 <br />Vehicle Type Color <br />License # Sticker # <br />to OCF0 0A0B <br />to 0 Ice Plant 0 Produce Stand <br />'SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facilit EINew EH Program and New Facility <br />Facility ID <br />Facility Address 1'4 5- S \ co )—rut- c 15'3% <br />(Please check the appropriate description and specif size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation :Wending Machines Number of Units <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 <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation <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 />El Poultry Farm Maximum number of birds %YEMENI <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) RECEIVED <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art FacilityABgt9 yse (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp ellit ftliZbiancility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # <br />El Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (# of units) 0 Dumpsters >20 Cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 -60 0 > 60 generators <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 .=).c or-,--75 Night Ph c--.)-•(..,S-c)c)--- SO7 <br />INS ECTOR # S -2. PERMIT VALID 17(.2 '2-12 to <br />FEE 0 P61 0 SurctIrge F E PROGRAM ELEMENT tk.0 <br />Check # 2-- AMOUNT PAID — Date ki7 2- d-0 <br />Cash REVIEWED BY ACCOUNTING OFFICE ' <br />Other FEE <br /> <br />Food Handler <br />INVOICE # For <br />Date 2, 23 <br /> <br />o UIC Site <br />Site <br />0 Chemical Toilets ----Number of trn <br /> Capacity <br />HS SAN AN AN LJTOH DA Q tRU le AN COUNTY N <br />Vailitherk <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />48-02-034 e?.,k_ <br />1/23/13 <br />MASTERFILE RECORD NFORMATION PINK