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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility ,New EH Pro ram and New Facilit <br />Sq <br />Facility ID OD3-771 — Program Record ID <br />—091 Facility Address 146)0 s. co yya 110 L.) T(4 C ,./ CA- <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 El Vending Machines Number of Units <br />,r4 Retail Market---Square footage 3/ 0 6 El w/Meat Market only 0 Multiple Departments 113( Prepackaged Goods Only <br />Mobile Food Vehicle -Make Vehicle Type Color <br />Registration # License # Sticker # <br />El Mobile Food Prep Unit- Make Vehicle Type Color <br />Registration # License # Sticker # <br />0 Temporary Food Facility -Dates of operation from to 0 Ice Plant 0 Produce Stand <br />0 Special Event--Dates of operation from <br /> <br />to El FO A El B <br /> <br />DAIRY PROGRAM (2000) <br />Grade A Dairy D 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 />El Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility -----> 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) El PBR (2231) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />jgf Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />El 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 NPLJSEP Cleanup Site 0 UIC Site <br />CI Abandoned HW Site 0 non-NPLJSEP Cleanup Site El RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility D 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 D 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 0 Chemical Toilets --Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station El Ag/Cannery Waste Site 0 Sludge/Ash Site <br />0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (# of Units; El Dumpsters > 20 cu yd (# of Units, 0 Farm/Ranch Cleanup Site <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 11 - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENC NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph 1_01-6'7IngIrTlight Ph .2-0q 676'aqi <br />7,23 <br />79 <br />PROGRAM ELEMENT \—+ FEE 0 Surcharge FEE <br />INSPECTOR # U\r\V\O‘t 'Er) PERMIT VAL. 2)- to 7 - \-- <br />Check # AMOUNT PAJ3OI.OD Date <br />CI Cash REVIEWED BY ACCOUNTING OFFICE <br />CI Other FEE <br />0 Food Handler <br />INVOICE <br />Date <br />48-02-034 <br />1/23/13 <br />MASTERFILE RECORD INFORMATION PINK