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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility ONew EH Program and New Facility <br />Facility ID F-4,,D02--ig) <br />Facility Address <br />0 with Food Preparation <br />w/Meat Market only <br /> Vehicle Type <br />Registration # License # <br />Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />Temporary Food Facility --Dates of operation from to <br />Special Event---Dates of operation from <br />Sticker # <br /> Color <br />Sticker # <br />0 Ice Plant 0 Produce Stand <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br /> <br />17R(Restaurant: Seating Capacityl, Square Footage <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br />Program Record ID Rzosi-i-ggs34- <br />r5 -Macilh CA <br />Food Handlers Course required: YES 0 No 0 <br />:Wending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />to 0 CFO 0 A 0 13 <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit <br /> <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 />0 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 />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 NPL/SEP Cleanup Site 0 UIC Site <br />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 <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) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <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 - 10 0 11 -60 BEe 6y ynerators <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM ja4C/l// <br />/v COUNT''' Day Ph Night Ph -11EALTHiff?AlMENTAI • <br />e F E 0 Other FEE <br />9/ 1 '22 <br />9)t7Lii--* Date IJ INvoicE# <br /> <br />ACCOUNTING OFFICE ("0_ Date / (+z3 <br />41 3/1-3)34 04-q2py jtt, p pet KL- it w)t insp. 00 Noe <br />0 Kennel <br />Capacity Vehicle # <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 Cu yd (# of Units) Site <br />0 Small Generator 0 Lim' IWO <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/ <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form _SAN 2023 <br />CONTACT PERSON <br />INSPECTOR # L PERMIT VALID <br />1=Iheck # AMOUNT PAID <br />v7ifyi REVIEWED BY <br />PROGRAM ELEMENT FEE It 35 o Surchar <br />to <br />ASTERFILE RECORI INFORMATION PINK <br />0 Food Handler <br />rownweivr