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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility EiNew EH Program and New Facilit <br />[Facility ID 6-"D <br />Facility Address 110 N EL DORADO 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 <br />Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />Retail Market----Square footage LI w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License 4 Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <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 <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 />o 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 U non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site C7 Water Quality Remediation Site <br />Li °l0`1,1"n <br />i/AK-Varig Area 0 Out of Service Pool/Spa <br />k\ 010.#1., <br />Facility-Single,f',-"434(11110'c <br />-Temp Event Mobile Facility (4131) <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />0 Small Generator 0 Limited Hauler <br />10 0 11 -60 0 >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 Sunitha Dulla Day Ph 408-338-8744 Night Ph 408-338-8744 <br />Program Record ID -2/Marinial <br /> <br />Food Handlers Course required: YES LI No 0 <br /> <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa <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 <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration 14 License # <br />Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (# of units) LI Dumpsters >20 cu yd (// of umts) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - <br />INSPECTOR # <br />Check # <br />Cash <br />48-02-034 <br />1/23/13 <br /> <br />1681 FEE $237 Surchar e FE <br /> PERMIT VALID I [0 b 2,A).2.- to 0 <br /> <br />\) 147 Pt- AMOUNT PAID 2\ --- Date <br /> <br />REVIEWED BY ACCOUNTING OFFICE4y/ <br />4-)coq -q-32,4 ib/2—/?-0 <br />Other FEE <br />?\)/oicE# 3 gy 3 <br />ate / "0,(/ <br />M STERFILE REC RD I ORMATION PINK <br />Food Handler <br />PROGRAM ELEMENT <br />9828