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*42434 <br />1122113 <br />I ---- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />_ 0 New EH Pro ram at Existing Facilit <br />MASTERFILE RECORD INFORMATI711:00wRE FORM <br />Prt.rn and New Facilit <br />I Facility ID a( 7 rC —7 Program Record ID T-`4 <br />Facility Address 2410 BELLEVIEVV ST <br />(Please check the appropriate description and specify size, number of units <br />AM <br />andFopoedrtiHnaenntdilenrfsorcrnoautirosne <br />1:7V <br />YES 0 <br />FOOD P <br /> <br /> <br />N <br />ROGR (1600) <br />Goods o Ej Only <br />estaurant: Se9t mg Capacity Syrare Footage <br />Units 0 Commissary IVDry storage only PEKwith Food Preparation OVending Machines Number of <br />0 Retail Market----Sguare footage CI w/Meat Market only 0 Multiple Departments 0 Prepackaged <br />0 Mobile Food Vehicle --Make Vehicle Type <br /> <br />Color On <br />Registration # License # Sticker it <br />O Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker 14 <br />0 Temporary Food Facility --Dates of operation from to ID Ice Plant 0 Produce Stand <br />DE 0 Special Event---Dates of operation from to 0CF0 0A <br />DAI Y PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit <br />CUPA <br />El 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 />0 PBR (2231) 0 PBR HHW (2236) <br />0 Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 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 <br />0 non-NPL/SEP Cleanup Site ID RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool <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 VehicleRegistration # License It <br />Pumper Yard 0 Package Treatment Plant El Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) 0 Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility Landfill 0 Transfer Station 0 AgICannery Waste Site <br />Refuse Vehicles (// of Units) 0 Dumpsters > 90 <br /> <br />— CU yd 0 of Units) <br />0 CIA Landfill Site <br />0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 100 <br />Small Generator 0 Limited Hauler <br />Primary Care ID Acute Care 0 Skilled Nursing 0 Large Generator <br />PUBLIC wATErz.s:ertz PR RAM (4600) Use PWS END 46-02-003 Blue Application Form <br />0 11 - 60 0 > 60 generators , <br />.71.-1.-4014/1i- <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM (20q) q/3 2 Ili'qc <br />CONTACT PERSON barr I < eL_______ Day Ph ao icy- V; Night Ph <br /> 0 Other FEE <br />iNPECTOR # <br /> <br />Date 0 Check II AMOUNT PAID <br />0 Food Handler <br />S <br /> <br />9828 PERMIT VALID to <br />INVOICE #____— <br />0 Cash REVIEWED BY ACCOUNTING OFFICE <br /> <br />Date i <br />MASTERFILERE ORD INFORMATION PINK <br />El Spa 0 Out of Service Pool/Spa ID Natural Bathing Area <br />0 Kennel <br />Capacity Vehicle <br />PROGRAM ELEMENT 1632 FEE 0 Surcharge FEE