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0 Spa CI Out of Service Pool/Spa 0 Natural Bathing Area <br />CI Kennel <br />D Food Handler <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility EINew EH Program and New Facility <br />Facility ID F -A ,D0;217 7-1'7S- Program Recor-d13-7p09-457-/-5- <br />Facility Address 43 1-13 PACtPt AQS StocKkor‘ CA Szo7 CI <br />and pertinent information <br />Food Handlers Course required: YES R No 0 <br />OVending Machines Number of Units <br />El Multiple Departments 0 Prepackaged Goods Only <br /> Vehicle Type Color <br />Registration # License # <br /> <br />Sticker # <br />CI Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # <br />Sticker # <br />CI Temporary Food Facility --Dates of operation from to <br />El Special Event---Dates of operation from to <br />Pease check the appropriate description and specify size. number of units <br />FOOD PROGRAM (1600) <br />El Restaurant: Seating Capacity 2- 5 Square Footage 1,100 si <br />Commissary El Dry storage only 0 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only n Mobile Food Vehicle --Make <br />0 Ice Plant El Produce Stand <br />CFO 0 A El B <br />DAIRY PROGRAM (2000) <br />El Grade A Dairy <br />CUPA <br />El Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />El Hazardous Materials Business Plan 19001 Number of chemicals: <br />El CalARP Program El Program 1 Facility 0 Program 2 Facility <br />CI Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility > CI CA (2232) 0 CE (2233, 2234, 2235, 2237) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />El Other CUPA Program <br />HOUSING PROGRAM t 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 />0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup <br />El Abandoned HW Site El non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site El <br />RECREATIONAL HEALTH PROGRAM 3601_1 <br />Number of Pools/Spas at Facility 0 Pool <br />VECTOR CONTROL PROGRAM (4000) <br />CI Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg 14110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use 14" <br />CI Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) I=1 Body Art-Temp Event Mobile Facility 2." <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License Capacity Vehicle <br />El Pumper Yard El Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />El Landfill CI Transfer Station El Ag/Cannery Waste Site CI Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CI andfill Site <br />Refuse Vehicles (r. of Units) El Dumpsters >20 cu yd of Units) El FA , 4...Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />D Primary Care CI Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator Utirfflereauler <br />0 Transfer Station El Veterinary Clinic CI Common Storage Facility 0 2 - 10 El - SO 14> 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (46001 Use PWS EHD 46-02-003 Blue Application Form <br /> <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM -IVA0.‘,/frocou <br />Day Ph(204) 41, 0 -5 0 i 4 Night ph17,0k-,04147- <br />PROGRAM ELEMENT (.023 FEE <br />INSPECTOR # <br /> PERMIT VALID <br />0 check AMOUNT PAID <br />/ <br />MASTERFILE RECORi INFORMATION PINK <br />El Program Program 3 Facility <br />El PBR'223Th El PBR HHW (2236) <br />Site El UIC Site <br />Water Quality Remediation Site <br />El Chemical Toilets ----Number of Units <br />2023 <br />CONTACT PERSON <br /> <br />ABlaret. AALLEcios. <br /> <br />48-02-034 <br />1/23/13 6 W(911 ( <br />h viyg REVIEWED BY ACCOUNTING OFFICE NO" 40- <br />Date lip! I2./2' INvoicE# <br />Date <br />CI Surcharge FEE <br />to [0131124 <br />El Other FEE '4