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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Pro•ram at Existing Facility ONew EH Pro•ram and New Facility <br /> <br />Facility ID <br /> p 2ffi <br />Facility Address <br />(Please check the appropriate description and specify §j3g, number of units and pert nent information.) <br />FOOD PROGRAM (1600) <br />E Restaurant: Seating Capacity sq <br />Commissary 0 Dry storage only <br />Vehicle Type Color <br />License # Sticker # <br />Vehicle Type Color <br />License # Sticker # <br /> to 0 Ice Plant 0 Produce Stand <br />Special Event--Dates of operation from to CI cF0 0 A 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 />0 Hazardous Waste Generator (2200) —> Tons Generated Per Year <br />0 Tiered Permitting Facility -----> 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 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 NPLJSEP Cleanup Site 0 UIC Site 0 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 0 Kennel <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 />0 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 VehicieRegistration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets --Number of Units <br />Program Record ID pij..) <br />ago? kk) VA,k)c.c 1R.di \". 900k CIA 7 Ci S5 VO <br />Retail Market—Square footage <br />Mobile Food Vehicle --Make <br /> <br />Registration # <br />Mobile Food Prep Unit— Make <br /> <br />Registration # <br />Temporary Food Facility —Dates of operation from <br />Square Footage 3kLit) 54f4 Food Handlers Course required: YES 0 No 0 <br />0 with Food Preparation OVending Machines Number of Units <br />0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />SOLID WASTE PROGRAM (4400) <br />Landfill <br /> <br />0 Transfer Station <br />0 Waste Tire Facility <br /> <br />0 Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />0 Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (# of Units) <br />0 Sludge/Ash Site <br />0 CIA Landfill Site <br />El Farm/Ranch Cleanup Site <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 <br />0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 <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 CAM' CArc Day Ph Cte.5-1$3 -Q66.7 Night Ph <br />Small Generator 0 Limited Hauler <br />11 - 60 0 > 60 generators <br />qzs -1%3-%&?___ <br />PROGRAM ELEMENT FEE Surc <br />PERMIT VALID I /)D to <br />0 Check # AMOUNT PAID 3 Date <br />o <br /> 48-02-034 <br />Cash REVIEWED BY ACCOUNTING OFFICE <br />1/23/13 <br />q-i32 z 169 <br />arge EE Other FEE <br />Food Handler <br />VOICE # 0 <br />Date 1( 247 2-3 <br />MASTERFILE R <br />INSPECTOR # <br />CORD INFORMATION PINK