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L SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Pro ram al ExIsting_aF *ew EH Program and Now F chit <br />Facility ID <br /> <br />Program Record ID erD <br />Facility Address if C ()VL.,A) 1KV 0 lc ri) <br />(Please check the appropriate description and specify size, number of units and pertinent Information.) <br />Food Handlers Course required: YES 0 No 0 <br />0k/ending Machines Number of Units 0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Sticker II <br />Color <br />Sticker It <br /> to 0 Ice Plant 0 Produce Stand <br />to 0 CFO A 0 B <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 />El Hazardous Materials Business Plan (1900) Number of chemicals: 0 CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility 0 Hazardous Waste Generator (2200) >-Tons Generated Per Year 0 Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) 0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms 0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />0 Hotel/Motel Number of Units 0 Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) 0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site 0 Abandoned HW Site 0 non-NPL/SEp Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site 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 0 Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />O Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) 0 Body Art Facillty-Sterilization (4121) 0 Body Art Temp Event Co-0rd (4130) 0 Body Art-Temp Event Mobile Facility (41 LIQUID WASTE PROGRAM (4200) <br />0 Pumper VehIcleRegistration tt License # Capacity Vehicle # 0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) 1 , 0 Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site 0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site 0 Refuse Vehicles (# of Units) 0 Dumpsters > 20 Cu yd (toot units) 0 Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) <br />0 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler 0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 0 > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use pws END 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON S R W 1 V/i SA Pr R (M-4 /1 I Day Ph it og -7og - 7( Night Ph <br />PROGRAM ELEMENT \ 1 /4,30Y' FEE l "6 ,1Q) -- a Surcharge FEE 0 Other FEE INSPECTOR # ‘--t S S C\ PERMIT VALID • 3 • Z-1 to 2 0 Food Ha dler 0 Check # AMOUNT PAID # /8, Date INVOICE # ---7T.-/ 0 Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 <br />1/23/13 <br />o b2-ck <br />9.c3-77 <br />Special Event---Dates of operation from <br />FOOD PROGRAM (1600) <br />Restaurant: Sealing Capacity. <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br />Registration <br />Mobile Food Prep Unit-- Make_ <br />Registration <br />Temporary Food Facility --Dates of operation from <br />Square Footage <br />0 with Food Preparation <br />w/Meat Market only <br />Vehicle Typo <br />License ft <br />Vehicle Type <br />License # <br />0 Out of Service Pool/Spa 0 Natural Bathing Area <br />MASTERFILE RECORD INFORMATION PINK