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1 , SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />L MASTERFILE RECORD INFORMATION FORM <br />Food Handlers Course required: YES El No 0 <br />:Wending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Vehicle Type Color <br />License # Sticker <br />Square Footage <br />0 with Food Preparation <br />El w/Meat Market only <br />0 Other FEE <br />ACCOUNTING OFFICE <br />- <br /> to <br />Date <br />REVIEWED BY <br />PROGRAM ELEMENT \ FEE <br />INSPEcToR # L_ PERMIT VALID <br />Check # AMOUNT PAID 1 L;) <br />Cash <br />48-02-034 <br />1r2a113 <br />0 Surcharge FEE <br />2 , 0 Food Handler <br />f INvoiCE#3 <br />fr'/ Date 416 <br />MASTERFILE RECO•D INFORMAT eN PINK <br />Facility Address 4193 Middlefield Dr Tracy Ca 95377 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br />Registration <br /> <br />Vehicle Type Color <br />Registration 4 License 4 Sticker 4 <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to --eCFO El A 0 B <br />Program Record ID <br />WIew EH Pro ram and New Facilit New EH Program at Existin Facilit <br />Facility ID <br />CI Mobile Food Prep Unit-- Make <br />DAIRY PROGRAM (2000) <br />Grade A Dairy D 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 />CI Hazardous Waste Generator (2200) > - Tons Generated Per Year <br />Tiered Permitting Facility > El 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 />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/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site Cl NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site El non-NPL/SEP Cleanup Site El RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility El Pool El Spa El Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 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 i,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 /> <br />License # Vehicle # 0 Pumper VehicleRegistration Capacity <br />O Pumper Yard 0 Package Treatment Plant El Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator <br />Transfer Station 0 Veterinary Clinic <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Sean Maxwell Day Ph 209-637-3067 Night Ph <br /> <br />Sludge/Ash Site <br />CIA Landfill Site <br />El Farm/Ranch Cleanup Site <br />El Ag/Cannery Waste Site <br />El Process/Recycle Facility <br />El Dumpsters > 20 cu yd (0 of units) <br /> <br />El <br />0 Common Storage Facility El 2 - 10 <br />Form <br />Small Generator El Limited Hauler <br />0 11 -60 0 >60 generators <br />290-637-3067