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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />ID <br />PF C 7* <br />sq JUN 1 0Al j0A ?V?1 <br />WV/Faciiity Address'L�11 V(tUCTG kic. SK �QtO[wt� , CP �1�?Oq yEAtr/ o A(MFCOIJAJ <br />(K ry <br />rto,3w, chid the appropriate description and specify IM, number of Unita and portinont Information ) ARTV41r <br />FOOD PROGRAM t1600) <br />]Restaurant Seating Capacity_ Square Foologe Food Handlers Course rant ed: YEs 0 No 0 <br />11 Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Unils <br />lI Rated! Market—Square footage ❑ wiMeal Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />D Mobile Food Vehicle -Mnke Vehicle Type — Color <br />Registration # License # Slicker # <br />0 Mobile Food Prep Unit- Make Vehicle Type Color <br />Registration # License # Sticker # <br />D Temporary Food Facility -Dales of operation from to 0 Ica Plant 0 Produce Stand <br />D Special Event—Dates of operation from to 0 CFO D A D B <br />❑ Grade A Dalry ❑ Grade B Dairy ❑ Mllk Dispeneor-Number of Containers in Multi -Head Unit <br />CUPA <br />0 Hazardous Materials Business Pian (1900) Number of chemicals: <br />0 CaIARP Program 0 Program i Facility D Program 2 Facility 0 Program 3 Facility <br />D Hazardous Waste Generator (2200)—> -Tons Generated Per Year <br />0 Tiered Permitting Facility --> OCA(2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231 I D PBR HHW (2236) <br />D Aboveground Storage Tank Facility (AST) (2800) Numberof ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use USTA and forms <br />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />0 Hotel/Motel—Number of Units D Jail or Exempt Institution —Number of Units <br />Employee Housing (2700) Use Employee HousinalLabor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />0 Environmental Assessment 0 UST -CAP Site 0 Local HW Cleanup Site 0 NPLISEP Cleanup Site 0 UIC Site <br />0 Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />mixer of Poolsl5pas at Facility _ ❑Pool 11 spa ❑ Out of Service Pool/Spa <br />❑Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />0 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 />6 Body Art Facility -Sterilization (4121) 0 Body Art Temp Event Coward (4130) 0 Body Art -Temp Event Mobile Facility (4131) <br />UoU1D WASTE PROGRAM (4200) <br />O Pumper VehlcleRegistration# License# Capacity. Vehide# <br />0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets —Number of Units <br />SOLID WASTE PROGRAM (4400) <br />0 Landfill 0 Transfer Station 0 AglCannery Waste Site 0 Sludge/Ash Site <br />0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility D CIA Landfill Site <br />O Refuse Vehicles(solunb) DDumpsters> 20 cu yd(nor urvls)_ ❑ FarmlRanch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />0 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 112 - 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 ANDIOR PROGRAM <br />CONTACT PERSON 1 Lh Day Ph E1U-g21- 2lbS Night Ph SAnr <br />PROGRAM ELEMENT H I I O FEE r t S 0 Sumh ��FFxEE 0 Other FEE <br />INSPECTOR# PERMIT VALID !- t0 ..Jr./ Z 0 Food Handler <br />❑ Check NAMOUNT PAID �J ZcvZi Date 4AW INVOICE# <br />OCash REvEwED by Acc NG OFFICE Date 2 <br />4M-om ktiSTERFAE RECORD e4FORVATION Fir:K <br />IRJ!13 /I <br />