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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN T <br />MASTERFILE RECORD INFORMATION FORM <br />Food Handlers Course required: Yr ,-, 1l No <br />Color - <br />License # <br />Vehicle Type <br />Sticker # <br />Vehicle Type Color <br />License # Sticker # <br /> to 0 Icsylant 0 Produce Stand <br />l2"-CF0 VA 0 P <br />0 Program 3 Facility <br />0 PBR (2231) 0 PBR HHW (223 <br />0 Spa 0 Out of Service Pool/Spa El Natural Bathing Area <br />0 Kennel <br />Capacity Vehicle # <br />0 Chemical Toilets --Number of Units <br />0 Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd of <br />m Sall Generator 0 Limited Hauler <br />0 11 ot) 0 >60 generators <br />CONTACT PERSON S61{-zi Day Ph6g4-9 q3 DPI Le Night Ph -qq3 —D13 (4, <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />0 New EH Proqram at Existing Facility <br />I Facility ID 6022012_, <br />[New EH Pro ram and New Fac lity <br />Program Record ID <br />Facility Address Gum 14.. p_itirWin c C Ln. Loliktr).(4A 615 <br />(Please check the appropriate description aid specify lin, number of units and pertinent information.) <br />EQQD2114062,1 (1600) <br />0 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 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle —Make <br />Registration # <br />Mobile Food Prep Unit— Make <br />Registration # <br />Temporary Food Facility —Dates of operation from <br />Special Event—Dates of operation from <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CLIPA <br />0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Un:t <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility <br />Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility --> 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CLJPA 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 Housinq/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 <br />Abandoned HW Site 0 non-NPLJSEP 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 <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 <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration 4 License <br />Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles P+ of (11,11,, <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator El <br />0 Common Storage Facility 0 2 - 10 0 Transfer Station 0 Veterinary Clinic <br />PUBLIC WATER SYSTEM PROGRAM (4600) Usu PWS END 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />PROGRAM ELEMENT t;;)06. FEE <br />INSPECTOR # ?la PERMIT VALID <br />AMOUNT PAID <br />cAfx 4 i7+74) <br />El Surchar <br /> to 1 <br />Date / <br />0 Other FEE <br />3 .2.5- 0 Food Handler <br />INVOICF # 3Cl//07 <br />0212L(