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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Program Record ID pkci s-4-3-1 <br />,C47,e )-\ <br />New EH Program at Existing Facility <br />Facility ID PI 0(`).2-37_35- <br />k53 `i 7c <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />License # Sticker # <br />Vehicle Type Color <br />License # Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />piCie; EH Pro.ram and New Facility <br />Facility Address <br />(Please check the appropriate ddscription and specify size, mber of units anelpertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 <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 Vehicle Type Color <br />Special Event---Dates of operation from to la-CF0 _EA 0 B <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 />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 LI non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa <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) O Body <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) O Body <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # <br />Pumper Yard <br /> <br />0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />0 Water Quality Remediation Site <br /> Capacity <br />0 Chemical Toilets <br />LI NaturRAVIME4Sfir <br />RECEIVED <br />0 Kennel <br />FEB 12 202/1 <br />Art Facility-Sin se 41219) <br />Art-Temp EventlfW <br />HEALTH DEPARTMENT <br />Vehicle # <br />----Number of Units <br />Landfill <br /> <br />0 Transfer Station <br />Waste Tire Facility LI Compost Facility <br />Refuse Vehicles (U of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd or units) <br />0 Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <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 0 > 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 PERSONXk-av,' ‘-"C" Pvl a 7-;779 6.• 5 Day Ph0.2 Night Ph <br />PROGRAM ELEMENT 1 60 5\ FEE 0 Surchar <br />INSPECTOR # 171 g PERMIT VALID to <br />0 heck # AMOUNT PAID Date ",0" -At <br />l'46 <br />IN Cash REVIEWED BY <br />4-02-034 MASTERFILE RE ORD NFORMATION PINK <br />e FEE <br /> 0 Other FEE <br />Food Handler <br /> <br />ACCOUNTING OFFICE <br />INvoicE# <br />Date 2._ <br />1/23/13