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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 F-ADD7_.--)70g <br />Wew EH Program and New Facility <br />Program Record ID <br /> FEE <br />PERMIT VALID <br />AMOUNT PAID <br />REVIEWED BY <br />Surchar <br />to <br />Date <br />ACCOUNTING OFFICE <br />PROGRAM ELEMENT <br />INSPECTOR # <br />Check # <br />Cash <br />48-02-034 <br />1/23/13 con(' 4t/02033,9 <br />Facility Address 7U <br />specify size, number of units and pertinent information.) <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <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 lant 0 Produce Stand <br />Special Event---Dates of operation from to rCFO 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 />LI 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 <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Q a lily Site <br />RECREATIONAL HEALTH PROGRAM (3600) R C <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural...6V? Area <br />JUN 0 z <br />Body Art Facilit;1/401aliiiICR4NTO1T2M0ENL) NT YT <br />Body Art-Temp Event Mobile Facility (4131) <br />Landfill <br />Waste Tire Facility <br />Refuse Vehicles (# 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 <br /> <br />O 11 - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON PAMn I ra Vk 210 V k. Day Ph <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />(Please check check the appropriate description and <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />0 Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Square Footage <br />0 with Food Preparation <br /> 0 w/Meat Market only <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) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) <br />LIQUID WASTE PROGRAM (4200) <br />El Pumper VehicleRegistration # License # <br />Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />El Transfer Station <br />0 Compost Facility <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (# of Units) <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />2(11 IC—(hocpight Ph o-trt 7( s- Lt(5(0 <br />Other FEE <br />Food Handler <br />INVOICE # 17 g( <br />Date 6 <br />MASTERFILE RECORD FORMATION PINK