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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 re"4-1,1) 2-11,9.1 <br />0New EH Program and New Facility <br />Program Record ID fie.D <br />Facility Address S-4-'÷ LOde St- • WI viI-CePt CA g 533(.0 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to XCFO ilitA 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 /> <br />Capacity Vehicle # Pumper VehicleRegistration # License # <br />0 Package Treatment Plant 0 Chemical Toilets ----Number of Units Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Transfer Station 0 Ag/Cannery Waste Site <br />Compost Facility 0 Process/Recycle Facility <br />Dumpsters > 20 cu yd (4 of Units) <br />11 - 60 <br />2023 <br />Day Ph c'\ -z oq crig6i6 Night Ph _ <br />PROGRAM ELEMENT FEE it D 0 Surchar eoFiee <br />PERMIT VALID to -?"7. to <br />AMOUNT PAID Date <br />REVIEWED BY ACCOUNTING OFFICE 01/7-er <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 />0 Kennel <br />Landfill <br />Waste Tire Facility <br />0 Refuse Vehicles (4 of units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 <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 PERSONA N(ar co,s (1J-I ec(ez_ <br />INS/PECTOR # <br />Nd Check It <br />Cash <br />3 <br />Other FEE <br />Food Handler <br />I VOICE # <br />ate <br />Sludge/Ash Site <br />CIA Landfill Site <br /> 0 Farm/Ran Site <br />RE N1 <br />Generator 0 Limite rraut) <br />yrators <br />SAN JoA QUIN COI/ tiaLvviROANEN Nry <br />7-8 Cm. rTAL PAR <br />MEN)" <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />1/23/13