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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM lk New EH Program at Existing Facility El New EH Program and New Facility Facility ID 610,272 Program Record ID T&2f7gZ1 Facility Address 49 E 10th St, Suite A, Tracy, CA 95376 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) cF JUN �Fp Nr 2% ')V1414 � 4 B�QU/A' M�Nr ElCPA Restaurant: DAIRY PROGRAM (2000) ❑ Tiered Permitt Seating Capacity Square Footage Food Handlers Course required: yes ❑ No 11 ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle --Make Vehicle Type Color CalARP Program Registration # License # Sticker # ❑ Mobile Food Prep Unit-- Make Vehicle Type Color Landfill ❑ Transfer Station Registration # License # Sticker # ❑ Temporary Food Facility --Dates of operation from to ❑ Ice Plant ❑ Produce Stand ❑ Special Event ---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Tiered Permitt ® ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit CUPA Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ 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 ing 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 USTA 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 Housing/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 of Pools/Spas at Facility _ ❑Pool ❑Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) MEDICAL WASTE PROGRAM (4500) ❑ Primary Care El Acute Care El Skilled Nursing El Large Generator 11 Small Generator El Limited ® Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) ❑B0 Art Facility -Single Use (4120) ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration # License # Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (#of units) ❑ Dumpsters > 20 cu yd (# of units) ❑ Farm/Ranch Cleanup Site Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 -10 ❑ 11 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02.003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Lisa Bates Day Ph 909.640.7895 Night Ph 209-6404895 PROGRAM ELEMENT 4110 FEE El SI 1:1 Other INSPECTOR# 1 S3 PERMIT VAL ElCheck# [� AMOUNT PAII) El Cash p REVIEWED BY t0 !� )0 Date ACCOUNTING OFFICE FEE 11 Food Handler INVOICE# 3GS Date '1 2 4a -UL -U34 /23!13 /`n f27� MASTERFILE RHCORD INFORMATION PINK 1.•C)�f•��f/� Off/ �//