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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM EH Program at El Mobile Food Vehicle --Make Vehicle Type Color Registration # License # Sticker # ElMobileMobile Food Prep UnMake Vehicle Type Color Registration # License # Sticker # ❑ Temporary Food Facility --Dates of operation from to ElIce Plant ElProduce Stand ❑ Special Event ---Dates of operation from to ❑ CFO ❑ A ❑ B R.. y1weivr ,ci vjeo MAR 26 2011 Facility Address 23 ?.�:&ea Aum f�c k nairl C^- �IROQUINCOUNTy (Please check the appropriate description and specify size, number of units and pertinent information.) HEALTH DEPgENTAL FOOD PROGRAM (1600) ElRestaurant: Seating Capacity. Square Footage Food Handlers Course required: YES ❑ No ElElCommissary ElDry storage only IJwith Food Preparation ❑Vending Machines Number of Units ElRetail Market ----Square footage ❑ w/Meat Market only ❑ Multiple Departments ElPrepackaged Goods Only DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser -Number of Containers in Multi -Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator (2200) ---------- >-Tons Generated Per Year ❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ 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 ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housino/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number X0 I to s at Facility _ ❑Pool ❑❑ VECTOR CONTROL PROGRAM (4000) 13 Poultry Farm -------Maximum number of birds Spa Out of Service Pool/spa ❑Natural Bathing Area ❑ Kennel TATTOO, BODY PIERCING, PERMANENT 11 Transfer Station El Veterinary Clinic El Common Storage Facility 1:12 - 10 1:1 COSMETIC PROGRAM (4100) �8ody Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) ❑Body Art Facility -Single BeU(4120) El Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) El Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) 1:1 Pumper Vehicle Registration # License # Capacity Vehicle # 1:3 Pumper Yard El Package Treatment Plant El Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill 1:1 Transfer Station 11Ag/Cannery Waste Site ElSludge/Ash Site ❑ Waste Tire Facility 11 Compost Facility ElProcess/Recycle Facility 11 CIA Landfill Site El Refuse Vehicles (# or Units) ElDumpsters > 20 cu yd (# of units) ElFarm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) 1:1 Primary Care El Acute Care 11 Skilled Nursing El Large Generator El Small Generator ❑ Limited Hauler CONTACT Ph PROGRAM ELEMENT Lf(J O FEE I � �� ❑ Sr INSPECTOR# PERMIT VALID 32Lt t0 1:1Check # AMOUNT PAID a• Date 11 Cash REVIEWED BY ACCOUNTING OFFICE 034 11231/ 1123/13 l/ Ph ❑Other FEE ❑Food Handler INVOICE # Date 11 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form CONTACT Ph PROGRAM ELEMENT Lf(J O FEE I � �� ❑ Sr INSPECTOR# PERMIT VALID 32Lt t0 1:1Check # AMOUNT PAID a• Date 11 Cash REVIEWED BY ACCOUNTING OFFICE 034 11231/ 1123/13 l/ Ph ❑Other FEE ❑Food Handler INVOICE # Date