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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />ID New EH Program at Existing Facility /New EH Program and New Facility <br />Facility ID r4c)() Program Record ID PeD5 4 gSI.3 I <br />Facility Address 1447 Promenade Circle, Tracy Ca 95376 <br />(Please check the appropriate description aid specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />D,Restaurant: Seating Capacity 2cluare Footage Food Handlers Course required: Yes No 0 <br />Commissary 0 Dry storage only M with Food Preparation 0Vending MachinesNumber of Units <br />Retail Market----Square footage U w/Meat Market only 0 Multiple Departments 0 Prepackaged Onods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker It <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Regislration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to 0 CFO CAOB <br />DAIRY PROGRAM (2000) <br />CI Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser -Number of Containers in MJIti-Head Unit <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 />Tiered Permitting Facility 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HI-IW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />El Underground Storage Tank Program (UST) (23C0) 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 />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-NPLISEP Cleanup Site 0 RWQCB Cleanup Site I: Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool D Spa 0 Out of Service Pool/Spa E Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds D 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) 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 I/ Capacity Vehicle <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site D Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles p oi units) 0 Durnpsters > 20 cu yd (Cot units) U Farm1Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 -60 I: 60 generators <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 Jennifer Dew Day Ph 510-258-5483 Night Ph <br />PROGRAM ELEMENT k-)09 FEE \-k")diO — 0 Surcharge .FEE _ 0 Other FEE <br />INSPECTOR # PERMIT VALID A:4:- s.--') -22) to \ -L- t - 2.`-1 1171 Food Handler <br />Ill Check #1 _),e ir AMOUNT PAID 56110° 4+K. OD Date ) M S 2_ INVOICE <br />ID Cash REVIEWED BY ACCOUNTING OFFICE /71 Date <br />48-02-034 <br /> <br /> MASTERFILE RECOR6 INFORMATION PINK <br />el2A-1 4/' <br />1/23113 <br />/ 72 7 4 )2-