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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility MNew EH Program and New Facility <br />Facility ID 00,2-8-1 Program Record ID Beia_CLOCY+.2— <br /> <br />Facility Address 110 N FL DORADO ST <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Commissary 0 Dry storage only 6 with Food Preparation <br />Restaurant: Seating Capacity s Square Footage <br />Retail Market----Square footage LI w/Meat Market only <br />CI Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # <br />Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # Sticker # <br />0 Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to 0 CFO 0A0B <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 Housino/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 <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <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 />0 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 # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Transfer Station <br />Compost Facility <br />CONTACT PERSON <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 />Sticker # <br />Color <br />0 Water Quality Remediation Site <br />0 Out of Service Pool/Spa 0 Natural Bathing Area <br />0 Kennel <br /> License # Capacity Vehicle # <br /> <br />0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />PROGRAM ELEMENT 1681 FEE $237.00 <br />4, 9828 INSPECTOR ft PERMIT VALID <br />Chec # AMOUNT PAID <br />DIC <br />Landfill <br />Waste Tire Facility <br />Refuse Vehicles (4 of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care <br />Transfer Station 0 <br />leAtoo evE0 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 17,,tpied Hauler <br />Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 -60 0 >"610/ gin6rayn-lz <br />SAN "410 PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form — JOAQL/ <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM 1/4411/7, iRO This.COUN <br />_ Kvndal Manch° Day Ph 209-636-7033 Night Ph 2O9-9384R7.4- <br />0 Surcha <br />to <br />Date <br />ACCOUNTING OFFICE <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (# of Units) <br />2 e F E 0 Other FEE <br />A 0 Food Handler <br />PM INvoicE # 3- &Mb <br /> <br />ri Mar <br /> <br />. Jiff Date <br />Sludge/Ash Site <br />CIA Landfi <br />Farm/Ra <br />MASTERFILE RECORD I ORMATION PINK