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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FOAM <br />New EH Program at Existing Facility dNew EH Program and New Facility <br />Facility ID FALY 27 Program Record ID -PkI)9-t-205 <br />Facility Addressc /9 02 0 C ria C 0 V I- 4- 5 f-ock .i.--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 Food Handlers Course required: YES 0 No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only 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 Plant 0 Produce Stand <br />Special Event---Dates of operation from to 0/CFO q A 0 B <br />DAIRY PROGRAM (2000) <br />CI 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 />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 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 />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 VehicleRegistration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant E1 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfillp <br />Refuse Vehicles (4 of Units) 0 Dumpsters > 20 cu yd (4 of Units) 0 Farm/Rank rlifehir <br />MEDICAL WASTE PROGRAM (4500) il CEA/A.1.1 <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limced Hauler'la <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2- 10 0 11 -60 0 >14:0e3ertit202 s 3 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form A111 Jr, ,.... _ %JAC?! ii ,„ _ <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM kijiNV/FiloW COUNTy <br />CONTACT PERSON rNre.-r-L, /Per .....1- L Li A.) .4 LTHDE,,ENTAL Day po(loco sl I 9 0 3 g Night Ph maorl. qrsv,r_ <br />F E 0 Other FEE <br />LI Food Handler <br />INVOICE # <br />ACCOUNTING OFFICE <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />PROGRAM ELEMENT Ue.20 () FEE t 0 Surclia <br />INSPECTOR # PERMIT VALID <br /> <br />AgY 23 to <br />VCheck AMOUNT PAID air le• • • Date <br />as • ▪ REVIEWED BY Date 7/13/2,3 <br />1/23/13