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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ New EH Program at Existing Facility 07 ew EH Pro ram and NevCFacilitv <br /> Facilit ID 3 Program Record ID <br /> Facility Address_'11LA Rtsm (A7 man r (�n q,5--3-3o <br /> i <br /> (Please check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) 9 <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES Nfl"No ❑ t <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market----Square footage ❑ w/Moat Market only ❑ Multiple Departments❑ Prepackaged Goods Only r <br /> ❑ Mobile Food Vehicle—Make _ _ Vehicle Type Color I <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ic Plant[I Produce Stand <br /> El Special Event---Dates of operation from to CFO IA ❑ B <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUPA <br /> ❑ Hazardous Materials Business Plan(1900) Number of chemicals: <br /> 11 1 <br /> CaIARP Program E1 Program 1 Facility El Program 2 Facility 11 Program 3 Facility13 € <br /> Hazardous Waste Generator(2200)---------->-Tons Generated Per Year , <br /> ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE (2233,2234,2235,2237) ❑ PBR(2231) ❑ PBR HHW(2236) <br /> ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs 1 <br /> ❑Underground Storage Tank Program (UST)(2300)Use USIA and B forms <br /> ❑ Other CUPA Program <br /> HOUSING PROGRAM(2400) <br /> I <br /> ❑ Hotel/Motel------Number of Units ❑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 ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC site <br /> ❑Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM (3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area r <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm-------Maximum number of birds ❑ Kennel $ <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art Facility-Single Use(4120) <br /> ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> 1 <br /> Landfill 11 Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site P <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site e <br /> ❑ Refuse Vehicles(#of units) _ ❑ Dumpsters>20 cu yd I#of units) ❑ Farm/Ranch Cleanup Site P <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 ❑ 11 -60 ❑ >60 generators <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 /> CONTACT PERSON Daisy Oc( Ucda Day Ph 510-566-4755 Night Ph <br /> PROGRAM ELEMENT 1608 FEE 186 <br /> ❑ Surcha ge FE El Other FEE <br /> INSPECTOR# 8788 PERMIT VALID I I <br /> �2&Ze� to ll1 ❑ Food Hantiler a <br /> ❑ Check# AMOUNT PAID Date I t Y ?iD Ji INVOICE# (tiL <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date l( <br /> 48-02-034 / <br /> 1123/13 �� l/�� 2--,;, MASTERFILE R COR INFORMATION PINK <br /> J� <br /> �l <br /> t <br />