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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />NPN EH Prpgram at Existing Facility ow rti rya rani II Id New Facility <br />Facility ID - rig-- cr-z-b-7,6,1 Program Record ID 6-1) 2-9 <br />Facility Address i,137 invy J)14 /77 cv., inicy 4 9.1-377 (I4Vm) , Please c,leek he Roproonste description aro sperify size, number of units arid pertinent Information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant Sestmg Capacit% Square I ()tinge <br />0 Commissary 0 Pry storage only 0 with Food Preparation <br />0 Retail Market----Square tootaae 0 w/Meal Market only <br />Mobile Food Vehicle --Make _ _ Vehicle Type <br />Registration * License <br />Mobile Food Prep Unit- Make Vehicle Type <br />Registration C_ License IS <br />Temporary Food Facility -Dates of operation from <br />:7 Special Event--Dates of operation from to 0 CFO ErA 0 B <br />DAIR) PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />LT Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Z Hazardous Waste Generator (2200)---> Tons Generated Per Year <br />Z Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW 223, <br />Z Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />2 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 MmGATioN (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPUSEP Cleanup Site 0 UIC Site <br />0 Abandoned HW Site 0 non-NPUSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Sita <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 />0 Poultry Farm—Maximum number of birds 0 Kennel <br />TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />0 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 />UQUID WASTE PROGRAM (4200) <br />0 Pumper Vehicle Registration # <br />0 Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />0 Landfill <br />0 Waste Tire Facility <br />0 Refuse Vehicles (a of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />0 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 D > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />gMERGENCY NOTIFICATION FOR THIS FACIUTY AND/OR PROGRAM <br />Day Ph _C_11,1ji_j_e- - Rs Night Ph <br />PROGRAM ELEMENT \ r()0( FEE C?:)kp 0 Surcharge FEE <br />INSPECTOR # L PERMIT VALID ' 2_0 • to S • 3 \ • 25 <br />Cheek # <br />O Cash <br />48-1,2tg34 <br />REVIEWED BY ACCOUNTING OFFICE <br />Food Handlers Course required: YES 0 No <br />0Vending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Sticker 11 <br />Color <br />Sticker It <br /> to 0 Ice Plant 0 Produce Stard <br /> License # <br />0 Package Treatment Plant <br /> <br /> Capacity Vehicle It <br />Chemical Toilets ----Number of Units <br /> <br />Transfer Station Ag/Cannery Waste Site ID Sludge/Ash Site <br />Compost Facility ID Process/Recycle Facility 0 CIA Landfill Site <br />0 Dumpsters > 20 cu yd lti ot Units) 0 Farm/Ranch Cleanup Site <br />CONTACT PERSON ciforaei Ale A-LiagsAd <br />AMOUNT PAID <br />0 Other FEE <br />0 Food 119?dler <br />Date INVOICE # 6/117;11P— <br />Date <br />AP4Ø5Ø9 mASTERM R CORD NECh