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New EH Program at Existing Facility :New EH Program and New Facility <br />Facility ID r/OO,---1(4 2__ Program Record ID <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility Address 2±\&O c;U\ <br />(Please check the appropriate description and specify size, number of units aed pertinent information.) <br />20 7_3 <br />PROGRAM ELEMENT \ \<._.).S. FEE 2 4 - 0 Surcharge FEE <br />INSPECTOR # C )\-A PERMIT VALID t --1 5- 23 to t 2 - \ - 2 LI <br />Check # AMOUNT PAID <br /> <br />2 37 , on Date <br />,'Cash REVIEWED BY ACCOUNTING OFFICE <br />4 -02-034 MASTERFILE RECO D INF RMATION PINK <br />1/23/13 <br />CI Other FEE <br />El Food Handler <br />INVOICE # <br />Date <br />Ow (73 cis 2 c, <br />11:EPECACI '1:151E112 OEN2 31; <br />SAN JOAQUIN <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />-Retail Market----Square footage <br />‘1.„. Mobile Food Vehicle --Make <br />Registration # C [ Z L.) b- <br />Li Mobile Food Prep Unit-- Make <br />Registration # <br />CI Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from to <br />ENVIRON C°UNTY HEAL 4LNT <br />Food Handlers Course required: <br /> TA4 <br />Ytt'ErA/110W4jr <br />:Wending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />to 0 Ice Plant 0 Produce Stand <br />0 CFO 0 A 0 B <br />Square Footage <br />0 with Food Preparation <br />w/Meat Market only <br />Vehicle Type <br />License /I (-{ S.3-.? <br /> Vehicle Type <br />License # <br />Sticker # <br />Color <br />Sticker # <br />DAIRY PROGRAM (2000) I(N s 0 (\f\ c <br />Grade A Dairy 0 Grade B 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 />CI Tiered Permitting Facility > CI 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 />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 />CI Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />CI Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site CI 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 />Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # Capacity Vehicle # <br />CI Pumper Yard CI Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (# of Units) 0 Dumpsters > 20 Cu yd (# of Units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator <br />CI Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />t EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON N\7\.('\ t 42\ (NE Day Ph 2-C7ri:%i 50'7-S2-2-alight Ph <br />0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />Small Generator 0 Limited Hauler <br />CI 11 - 60