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I <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />131New EH Program and New Facility_ <br />r Program Facility jp.,2&2zicx23_ I Aocaigii Facility ID <br />Facility Address 110 N EL DORADO ST <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity Square Footage <br />IN Commissary 0 Dry storage only 6 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />Mobile Food Vehicle --Make <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 />0 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 Housinq/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 U1C 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 <br /> <br />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 />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # <br />Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Transfer Station 0 Ag/Cannery Waste Site <br />Compost Facility 0 Process/Recycle Facility <br />0 Durnosters > 20 cu yd c# or units) <br />Small Generatc* <br />0 11 - 60 <br />1681 FEE $237.00 0 Surchar 0 Other FEE <br /> PERMIT VALID fiilAs to 2 • 0 Food Handler <br /> AMOUNT PAID Date <br />gmaw ird INVOICE # 3 <br />REVIEWED BY ACCOUNTING OFFICE Date 2. <br />48-02-034 <br />1/23/13 <br />AtZlcjek 0a./Udi 01-4- <br />MASTERFILE RECORD I FORMATION PINK <br />PR Ds LIci 003 <br />0 New EH Program at Existing Facility <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />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 /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />Landfill <br />Waste Tire Facility <br />Refuse Vehicles (# or units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />XMERGE, CNI NOT FICATION FOR THIS FACILITY AND/OR PROGRAM <br />DOriZef Day Ph(i) -5t/ScNight Ph Oirve., CONTACT PERSON <br />PROGRAM ELEMENT <br />INSPECTOR # 9828 <br />Sludge/Ash4rik4tA s <br />Cl CIA LandfAlj,Site lq <br />0 Farn arigN/plerupWo <br />"s.s.. <br />H2ulgef <br />k wifwgr.s <br />"T 4k-,11, <br />20