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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION ORM <br /> <br />xiirfl New EH Program at Existing Facility New EH Program and New Facility <br />Facility 11-- V17 am1- D Program Record ID <br /> 61Kssi-2 <br />Facility Address I00 LLW i6L--aq.2.1 0 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />N Restaurant: Seating Capacity Square Footage Z, )()▪ U D <br />CI Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />Mobile Food Vehicle --Make <br />Registration # <br /> <br />License # <br />CI Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />CI Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />El Grade A Dairy <br />CUPA <br />0 Grade B Dairy CI Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />CI Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program CI Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />CI Hazardous Waste Generator (2200) > -Tons Generated Per Year <br />CI Tiered Permitting Facility > D CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) CI 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 />CI Other CUPA Program <br />HOUSING PROGRAM (2400) <br />CI 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 CI Local HW Cleanup Site 0 NPUSEP Cleanup Site 0 UIC Site <br />CI Abandoned HW Site El non-NPUSEP Cleanup Site CI RWQCB Cleanup Site CI Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility El Pool 1=1 Spa CI Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />CI Poultry Farm Maximum number of birds <br /> 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 />CI Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />CI Transfer Station <br />0 Compost Facility <br />1.--) I EMERGE <br />CONTACT PERSON r.:7)74, <br />PROGRAM ELEMENT ti02— " FEE El Surch <br />INSPECTOR # \)1 D \rt) PERIVIIT VALID I 1 ij° to <br />CI Check # V i‘D ki"-- AMOUNT PAID 3 Date 1 <br />ACCOUNTING OFFICE <br />iç <br />Food Handlers Course required: YES No El <br />OVending Machines Number of Units <br />0 Multiple Departments CI Prepackaged Goods Only <br />Vehicle Type Color <br /> <br />Sticker # <br />Color <br /> <br />Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />i74 <br />Landfill <br />CI Waste Tire Facility <br />CI Refuse Vehicles ( of units) <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care 0 Acute Care CI Skilled Nursing 0 Large Generator <br />CI 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 />Y NOTIFICATION FO THIS FACILITY AND/OR PROGRAM <br />titSatte'K.Day Ph 70C1-4j43--705 Night Ph )1) 411 EgITC <br /> <br />License # Capacity pA Vehicle # <br /> <br />0 Package Treatment Plant 0 Chemical Toilets ---NumbiERE4 /vr <br />/1/,E•D <br />CI Ag/Cannery Waste Site JL1t1 §li up giyAgh Site <br />CI Process/Recycle Facility ,,,,,,RCIA LW411 Site <br />4 0 Dumpsters > 20 CU yd (# of Units) t04tritanch Cleanup Site <br />CI Small Generator 0 Limited Hauler <br />il-SO 0 > 60 generators <br />CI Cash REVIEWED BY <br />41 /82- 03121-30 3 4 165 6 <br />Food Handler <br />ftyl Date <br />iNVOICE # <br />MASTERFILE R COI INFORMATION PINK <br />Other FEE