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RD <br /> 22 <br />FORMATION FORMATION PINK <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility :New EH Program and New Facility <br />FacilityID F oc) 277 (,„-) -2 Program Record ID ppos+s 4135 - <br />Facility Address 9 9 ?5 ()Rion) (Quin <br />(Please check the appropriate description and specify size number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity Square Footage <br />0 Commissary 0 Dry storage only 0 with Food Preparation <br />0 Retail Market---Square footage 0 w/Meat Market only <br />0 Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # <br />0 Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />0 Special Event---Dates of operation from <br />0 Temporary Food Facility --Dates of operation from <br /> to )(CFO pkix 0 B <br />to 0 Ice Plant 0 Produce Stand <br />DAIRY PROGRAM (2000) <br />EI Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />0 Hazardous Materials Business Plan (1900) Number of chemicals: <br />0 CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />0 Hazardous Waste Generator (2200) ------ --->-Tons Generated Per Year <br />0 Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />0 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 />0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPLJSEP 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 />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 />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 />0 Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) El Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />0 Pumper Vehicle Registration # License # Capacity Vehicle # <br />ID Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets —Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 AgICannery Waste Site <br />0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />0 Refuse Vehicles l of units) 0 Dumpsters > 20 cu yd or 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 />0 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 />U <br />0 Sludge/Ash Site <br />0 CIA Landfill Site <br />0 Farm/Ranch Cleanup Site <br />CONTACT PERSON i<Risimp, 0 Night Ph_6(gt)953-30)7_ <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br /> Color <br />Sticker # <br />Day Ph <br />PROGRAM E EMENT On FEE <br />INSPECTOR # I 'AA PERMIT VALID <br />0 Check # AMOUNT PAID <br />o Cash REVIEWED BY <br />e_49-P. /Col <br />48-02-034 <br />1/23/13 <br />ACCOUNTING OFFICE <br />0 Surcharg FE <br />to <br />Date INVOICE # <br />Date <br />MASTERFILE IRE <br />O Other FEE <br />0 Food Handler