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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facilit ErNiew EH Program and New_Fapilily_v <br />Facility ID Program Record ID cr,05---- zwy5 <br />Facility Address -7; _r;.0 CkikitScx A6c_rl?),,\ 152.01 <br />(Please check the appropiTaTe-description and specify size, number of units and pertinent 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 :Wending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only El Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # 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 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-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 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 NPUSEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water QualityMcM1Mte <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Nagg <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 KcenLI3 ° <br />SAN JOAQUIN COUNTY <br />TAL 0 Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-SinA WTMENT <br />0 Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event o Ile aci ity (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License #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 0 Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (# or Units) 0 Dumpsters > 20 cu yd (# of Units) 0 Farm/Ranch 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 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form j 112 0 <br />CONTACT PERSON{ ATY 1 C., I 6( 6.104.1 7-61 I e -a_ Day PIS 00 61 1/4q,alight Ph <br />nv(ic!icirmi'LiaCilLtoii{ <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM 90 11241e Z r" <br />2024 <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />PROGRAM ELEMENT f FEE <br />INSPECTOR # (0( PtRMIT VALID <br />Check # AMOUNT PAID <br />24 <br />ash REVIEWED BY <br />8-02-034 <br />1/23/13 <br />ACCOUNTING OFFICE <br />Surcha ge F <br />to <br />Date 010 <br />/j Date <br />ASTERFILE F1 CORD II4FORMATION INK <br />0 Food Handler