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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />0 Ice Plant 0 Produce Stand <br />0 Kennel <br />Capacity Vehicle # <br />23 <br />auler <br />rators <br />New EH Program at Existing Facility 'New EH Program and New Facility <br />1 Facility Address 2 °1 00 E LA,,,iy 5 i6ck <br />Facility ID i/Da17(,..-S72 Program Record ID ?easli-g%1 <br />Square Footage Food Handlers Course required: YES 0 No 0 <br />0 with Food Preparation OVending Machines Number of Units <br /> <br /> 0 w/Meat Market only 0 Multipls Departments 0 Prepackaged Goods Only <br />1:21. Mobile Food Vehicle --Make .5 1) C. A) 5 Vehicle Type TM I 'P.-- Color <br />Registration # C A 12 2.,,,q17._ License # (-11—SS /1 Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <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 />Poultry Farm Maximum number of birds <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 />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Unita <br />SOLID WASTE PROGRAM (4400) 1-YINE <br />ir Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 SlaSeplifiV . <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 IC:4141AndiTif gialp <br />Refuse Vehicles (# of Units) 0 Dumpsters > 20 cu yd (ti of Units) Vi5heanup Site <br />MEDICAL WASTE PROGRAM (4500) SAN JO <br />0 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Geneeflm <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 ii-T4477/ 1144krgt n <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form ARTMENT <br />\ EMERGENCY NOTIFICATION FOR THIS FACI ITY AND/OR PROGRAM <br />'Pi Day Ph oc. 6 -So Night Ph ( 201)ggC2g OF, CONTACT PERSON Dc- <br />PROGRAM ELEMENT 1(0 (5 FEE $2*-51- 0 Surcharge FEE 0 Other FEE <br />INSPECTOR # C(62(2.) PERMIT VALID 5/25123 to /21303 0 Food Handler <br />A•-•.--.--* 0 Check # AMOUNT PAID ,f2zJ 1. Date 5. )2- 512 INvoicE# 3g gg <br />2( Ca s 142.3 .q.—REVIEWED BY 6.) T-- _ ACCOUNTING OFFICE d/19- Date <br />48-02-034 MASTERFILE RECORETINFORMATION PINK <br />1/23/13