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r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />ram at Existing Facility <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />El Restaurant: Seating Capacity Square Footage <br />Commissary 0 Dry storage only Li with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />Registration tl License # <br />Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />DAIRY PROGRAM (2000) <br />1:1 Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <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) CI 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 />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 <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) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles to ot units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care El Skilled Nursing 0 Large Generator 0 Small Generator <br />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 />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />?cricL S,A f\buo-y Day Ph (Al -203 - VISLI Night Ph <br />REVIEWED BY ACCOUNTING OFFICE <br />AMOUNT PAID '/ <br />PERMIT VALID4" cii2e0/2,3 <br />FEE 0 Surcharpe F E 01 Other FEE <br />' • .(), <br />Date <br /> <br />to D Food Handler <br /> INVOICE # <br />MASTERFILE R <br />Date ? <br />CORD I FORMATION PINK <br />240 .23 <br />7 7C <br />48-02-034 <br />1/23/13 <br />0 New EH Pro 'New EH Program and New Facility <br />Facility ID Program Record ID ?l2b5-1-i-g <br />k C 95 211- Facility Address 50( S‘AnhAry 4, <br />S4 N Jo 2 0 202 <br />114/LVV 4-jiN C <br />Food Handlers Course required: YES No 0 <br />:Wending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br /> Color <br />Sticker # <br />Color <br />Sticker # <br />Li Temporary Food Facility --Dates of operation from to El Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to CFO A 0 B <br />0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />0 Kennel <br />Body Art Facility-Single Use (4120) <br />Body Art-Temp Event Mobile Facility (4131 <br />License # <br />0 Package Treatment Plant <br /> Capacity Vehicle if <br />0 Chemical Toilets ----Number of Units <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Li Dumpsters > 20 cu yd (II of Units) <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Sit <br />0 Limited Hauler <br />0 > 60 generators <br />CONTACT PERSON <br />PROGRAM ELEMENT <br />INSPECTOR # <br />Check # <br />Cash