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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />ki New EH Program at Existing Facility 0New EH Program and New Facility <br />[Facility ID _MO027/40 I Program Record ID PtZ05/1-. g. <br />Facility Address 7?-"-1 1 NA -c, —\ FA c, "3"-/ <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />0 Temporary Food Facility --Dates of operation from to CI Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br /> <br />0 grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility CI Program 3 Facility <br />0 Hazardous Waste Generator (2200) >- Tons Generated Per Year <br />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 />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 Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />0 Environmental Assessment p UST-CAP Site D Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />0 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 0 Spa 0 Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />0 Poultry Farm Maximum nurnber of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (41i0) 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 Vehicle Registration # License # Capacity Vehicle # <br />0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />Commissary 0 Dry storage ohly 0 with Food Preparation <br />Retail Market--Square footage 0 w/Meat Market only <br />0 Mobile Food Vehicle --Make ' Vehicle Type <br />Registration # License # <br />Food Handlers Course required: YES Eli No 0 <br />LIVending Machines Number of Units <br />Multiple Departments 0 Prepackaged Goods Only <br /> Color <br />Sticker # <br />to 0 CFO A 0 B <br />CI Kennel <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters >20 Cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) ' <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator <br />0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 ii - 60 <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 CACI; 't \ct k E-." CAA ckui-e--7..... Day Ph ( LAC ) k y C; --(,c ,,i --1 Night Ph <br />FEE 186 0 Surcharge FEE 0 Other FEE <br />MIT VALID j — k 5 - 23 to ‘ k —3 r' 2_,L-1 0 Food Handler <br />NT PAID 1 Wo. LDZI;, Date / I / 4 23 INVOICE # <br />I <br />elotr 1 /7/ 73O3 <br />SOLID WASTE PROGRAM <br />Landfill <br />Waste Tire Facility <br />Refuse Vehicles (# of <br />(4400) <br />Transfer Station <br />Compost Facility <br />Units) <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />0 Limited Hauler <br />0 > 60 generators <br />48-02-034 <br />1/23/13 <br />PROGRAM ELEMENT 1608 <br />INSPECTOR /I 4589 PEF <br />Check # Amou <br />Cash REVIEWED BY ACCOUNTING OFFICE Date <br />MASTERFILE RECORD INFORMATION PINK <br />14 z3