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New EH Program at Existin Facilit New EH Pros ram and New Facility <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATIO:ORM <br />0 Food Handler <br />INVOICE # <br />Date ? <br />MASTERFILE COD INFORMATION PINK <br />3 <br />Facility ID rilOC.)=23-75.— Program Record ID ?eas-i-i-,s1D,_ <br />Facility Address 9 w. L.0 r it ST <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 L1No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation :Wending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br /> <br />0 Mobile Food Vehicle --Make Vehicle Type Color <br /> <br />Registration # License # Sticker # <br />1!1 Mobile Food Prep Unit-- Make Vehicle Type e ;MT Color <br /> <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 0 A 0 B <br />DAIRY PROGRAM (2000) <br />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 />0 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 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 <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 FAymeivr <br />SOLID WASTE PROGRAM (4400) <br />MEDICAL WASTE PROGRAM (4500) <br />0 Landfill <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <br />0 Transfer Station <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (# of Units) <br />0 Ag/Cannery Waste Site <br />aN JOAQUIN COUNTy <br />0 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Gener. z ?Mettler <br />0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 • • <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON <br /> p, PERpENCY NOTIFICATIODI,FOR THIS FACILITY AND/OR PROGRAM <br />Mit naopt Day Ph 2o9. 9 00- (Kgight Ph 2011-Criaa . !K2 <br />PROGRAM ELEMENT tg g FEEVI 75P .° ° Surch EE 0 Other FEE <br />INSPECTOR # 5 7-5' PERMIT VALID Ctif4/..2 10 <br />DEI;i heck # • AMOUNT PAID Date <br />h V1514 REVIEWED BY ACCOUNTING OFFICE <br />48-0 -034 <br />1/23/13 <br />0 Kennel <br />REEI <br />Sludge/AshCV= <br />r% <br />5Ttb" 16. LI <br />CIA Wilpiteln <br />Farm/Ranch die6144 Site