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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility <br />Facility ID "Pl40D 276,6;7 <br />iNew EH Program and New Facility <br />Program Record ID -Peas--4,s 414-p-f <br /> Color <br />Sticker # <br /> Color <br />Sticker # <br />0 Ice Plant 0 Produce Stand <br />9 6-(01) <br />Facility Address 3 '4 11— E. Nom E (2. <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br /> Square Footage <br />Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br /> <br />ErMobile Food Vehicle --Make Vehicle Type <br /> <br />Registration # <br />Mobile Food Prep Unit-- Make <br /> <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments ErPrepackaged Goods Only <br /> <br />License # <br /> <br /> Vehicle Type <br />License # <br />to <br />to <br /> 0 CFO 0 A 0 B <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 />0 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 0 UIC Site <br />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 />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Poultry Farm Maximum number of birds <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) <br />LI Body Art Facility-Single Use (L.1,a) Body Art Practitioner Reg (4110) <br /> <br /> 0 Mechanical DSPS Notification (4115) <br />0 Body Art-Temp Event Mobile WAiliti Or 1 2 42 3 <br />0 Kennel PAYMENT <br />RECEIVED <br />LIQUID WASTE PROGRAM (4200) <br />SAN JOAQUIN COUNTY <br /> License # Capacity Vehicle INVIRONMENTAL Pumper VehicleRegistration # <br />0 Chemical Toilets ----Number of Units HEALTH DEPARTMENT Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br /> • Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility <br /> O Process/Recycle Facility <br />Refuse Vehicles (4 of Units) <br /> • Dumpsters > 20 cu yd (4 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 1 1 — 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 w- Day Ph .)-0- - - )).1 Night Ph <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />PROGRAM ELEMENT I Li- FEE 01 • 0/ Surc4ge F <br />INSPECTOR # -94ef PERMIT VALID 6t/5-- ;V 2— 5 to W 24 2-3 <br />Check #V AMOUNT PAID kitYq- Date Aff2-3 <br />Cash REVIEWED BY ACCOUNTING OFFICE/ /70 <br />jr(, 48-02-034 2 q <br />MASTERFILE RECORD INFORMATION PINK <br />1/23/13 <br />Other FEE <br />Food Handler <br />I N VO IC E # 65-6. <br />Date