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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility CgiNew EH Program and New Facility <br />Facility ID Do 2-73'6(e:2— Program Record ID F20,5-1-t-s-4141 <br />Facility Address 1658 S AIRPORT WAY <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) 101+ <br />t4 Restaurant: Seating Capacity Square Footage <br />Commissary CI Dry storage only 0 with Food Preparation <br />Retail Market----Square footage C7 w/Meat Market only <br />Mobile Food Vehicle --Make <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />CI Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />CI Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />El Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program 0 Program 1 Facility CI Program 2 Facility 0 Program 3 Facility <br />CI Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility > CI CA (2232) 0 CE (2233, 2234, 2235, 2237) CI PBR (2231) CI PBR HHW (2236) <br />CI Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />CI Hotel/Motel Number of Units CI 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 />El Environmental Assessment CI UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site CI U IC Site <br />CI Abandoned HW Site El non-NPL/SEP Cleanup Site GI RWQCB Cleanup Site CI Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility CI Pool <br />VECTOR CONTROL PROGRAM (4000) <br />CI Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />El Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) El Body Art Facility-Single Use (4120) <br />CI Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper VehicleRegistration # License # Capacity Vehicle # <br />El Pumper Yard 0 Package Treatment Plant CI Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill CI Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site <br />CI Waste Tire Facility CI Compost Facility CI Process/Recycle Facility 0 CIA Landfill <br />Refuse Vehicles or Units) El Dumpsters > 20 cu yd or Units El Farm/Ranck~ittAi <br />MEDICAL WASTE PROGRAM (4500) Nett <br />CI Primary Care 0 Acute Care 0 Skilled Nursing CI Large Generator CI Small Generator 0 Lirpited Haufer E.0 <br />CI Transfer Station Cl Veterinary Clinic CI Common Storage Facility CI 2-10 0 1 1 - 60 0 >latil kierp4atov, <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS 03 EHD 46-02-0 Blue Application Form SAN Jo 4U24 <br />Ian()Day Ph Eza) SC / Night Ph 1.1 "41-riy DI.AipmE.Ivc7 )-Ati Lvry <br />0 Surcharge FEE <br />INSPECTOR # 9828 PERMIT VALID III Li-- to 2.12F1/5 CI Food Handler <br />CI check # AMOUNT PAID fio diq Ii Date 2t1 4 ( -2_4-1- INVOICE # <br />al/C \I& REVIEWED BY ACCOUNTING OFFICEW-11 all*-- Date <br />MASTERFILE RE ORD NFO MATION PINK <br />Note: Okay to issue permit (SR0087567) <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />CI Multiple Departments CI Prepackaged Goods Only <br />Vehicle Type Color <br />License # Sticker # <br />Vehicle Type Color <br />License # Sticker # <br />to 0 Ice Plant CI Produce Stand <br />to 0 CFO El A 0 B <br />CI Spa El Out of Service Pool/Spa CI Natural Bathing Area <br />CI Kennel <br />CONTACT PERSON /11 <br />— EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM EA/14Q1j/N C <br />PROGRAM ELEMENT 1626 FEE $425 CI Other FEE <br />48-0 034 e <br />1/23/13 -W. r4co-tq-cog3g