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LI Ag/Cannery Waste Site <br />0 Process/Recycle Facility <br />LI Dumpsters > 20 cu yd (# of Units) <br />LI Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />Pc1)211 LD1-39- <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility )3ZiNew EH Program and <br />Facility ID Program Record ID t 2-if <br />Color <br />0 Ice Plant 0 Produce Stand <br />0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />Grade B Dairy U Milk Dispenser -Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />LI CalARP Program 0 Program 'I 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) U CE (2233, 2234, 2235, 2237) 0 PBR (2231) U PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />El Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />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 D UST-CAP Site U Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPLJSEP 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 D 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 />CI 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) DI Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant U 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 LI Small Generator 0 Limited Hauler <br />Transfer Station D Veterinary Clinic LI Common Storage Facility U 2-10 0 11 -60 0 >60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />9 CONTACT PERSON Debbi Rogers Day Ph 209-839-8759 Night Ph 209-610-4433 <br />New Facility <br />' °OD 1.1) 0033 <br />O Facility Address 7000 Coriander Street, Tracy, CA 95377 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br /> <br />0 Restaurant: Seating Capacity <br />DI Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br />Square Footage Food Handlers Course required: YES 0 No C] <br />0 with Food Preparation OVending Machines Number of Units <br />0 w/Meat Market only U Multiple Departments 0 Prepackaged Goods Only <br /> Vehicle Type <br />Registration # License # <br />0 Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />Temporary Food Facility --Dates of operation from to <br />Special Event---Dates of operation from to <br />Sticker # <br />Color <br />Sticker # <br />INSPECTOR # <br />Check # <br />Cash <br />48-02-034 <br />1/23/13 <br /> <br />0 Surcharge FEE 0 Other FEE <br />k-1 to t+C) ' 2J0* 2- _S D Food Handler <br />AMOUNT PAID Date INVOICE # <br />REVIEWED BY ACCOUNTING OFFICE iga Date 'Egg <br />MASTERFILE REC RD I FORMATION PINK <br />PROGRAM ELEMENT \ :1:3? FEE xe <br />PERMIT VALID (r) • •