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ASTERFILE REC RD INF RMATION PTIK 48-02-034 <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program 0 Program 1 Facility El Program 2 Facility <br />Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility > El CA (2232) 0 CE (2233, 2234, 2235, 2237) <br />El Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />El Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />El Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units El Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/L. - Camp Application Form <br />SITE MITIGATION (2900) Ur., ‘ERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site El 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 El Pool <br />VECTOR CONTROL PROGRAM (4000) <br />El 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) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration <br />0 Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />El Landfill El Transfer Station <br />Waste Tire Facility El Compost Facility <br />El Refuse Vehicles of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />El Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 <br />Transfer Station 0 Veterinary Clinic El 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 FACI ITY AND/OR PROGRAM <br />Day PI :2jO) W3.-"" Yr! tNight Ph LsiOrioS -‘) <br />El Surcharge FEE El Other FEE <br /> to ID Food Handler <br />Date I I. ?A9 2)-3 I VOICE # 5 c2.-4D <br />Date <br />El Program 3 Facility <br />El PBR (2231) El PBR HHW (2236) <br /> <br />El Spa El Out of Service Pool/Spa 0 Natural Bathing Area <br /> License # <br />0 Package Treatment Plant <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />0 Dumpsters > 20 Cu yd (11 of unos) <br />Small Generator 0 Limited Hauler <br />0 11 - 60 El >60 generators <br />CONTACT PERSON <br />PROGRAM ELEMENT <br />INSPECTOR it <br />'Whack it <br />Cash REVIEWED BY <br />FEE <br />PERMIT VALID <br />AMOUNT PAID <br />ACCOUNTING OFFICE <br />PAYMENT, <br />Body Art FRWIgYeY2 (4120) <br />Body Art-TED-Lye/1 Mile Facility (4131) <br /> Capacity SJ4 JOAQUINNAIIASV <br />0 Chemical Toilets <br />El YMudgTe/MAEsNhTSite <br />0 CIA Landfill Site <br />El Farm/Ranch Cleanup Site <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility lErNiew EH Program and7lew Fa ility <br />[Facility IDer-4:-TV /./1" _ _ Program Record_ ID <br />Facility Address 47-5 C a AC--6-41A C4 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Food Handlers Course required: YES 0 No 0 <br />ElVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />Sticker # <br />to <br /> 0 Ice Plant 0 Produce Stand <br />0 CFO 0 A 0 B <br />0 Restaurant: Seating Capacity <br /> <br />Square Footage <br />Commissary 0 Dry storage only <br /> 0 with Food Preparation <br />Retail Market----Square footage _ w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />Registration it License # <br />Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />El Grade B Dairy El Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />1/23/13