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cbco <br />1M9v, <br />o Surchar•eF <br />to <br />Date <br />ACCOUNTING OFFICE <br />• <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility Address (+45 H 6A 0 ci1:52 (A- <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />Registration # <br />Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to yi,CF0 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 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 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 (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />New EH Program at Existing Facility ONew EH Program and New Facility <br />Facility ID At 1 16/ t)2 2.F1 Dt;q Program Record ID <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Mobile Food Prep Unit-- Make <br />Registration # <br /> License # Sticker # <br /> Vehicle Type Color <br />License # <br />LIQUID WASTE PROGRAM (4200) <br />El Pumper VehicleRegistration # <br />Pumper Yard <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 <br />Transfer Station 0 Veterinary Clinic <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />Nursing 0 Large Generator 0 Small Generator <br />0 Common Storage Facility 0 2 - 10 0 11 - 60 <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 Cu yd (# of Units) <br />Sludge/Ash 04 yilf,„, <br />CIA Landfill ffEcte. <br />Farm/RancVlean itto <br />ive n <br />DS1jk d Ha de t7024 <br />giti*I;844/Ap88-s <br />License # <br />0 Package Treatment Plant <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form Dzkittivruivry <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />Pktr <br />iNsir 2-i>1 i I CONTACT PERSON e, -rt i -1 Day Ph )( (#•), -,/77i- Night Ph / ) <br />PROGRAM ELEMENT I LOOb FEE <br />INSPECTOR # PERMIT VALID <br />E(Check # 11(6 b AMOUNT PAID <br />Cash REVIEWED BY <br />Other FEE <br />Food Handler <br />INVOICE # 3 <br />Date ,40 <br />48-02-034 MASTERFILE RECORD INF si'MATION PINK <br />1/23/13