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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Prorn at Existing Facilit ,New EH Pirlorm and <br />Program Record ID V <br />ew Facility <br />Facility ID <br /> <br />Facility Address -5, t au6 c); 41 75zr, <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />El Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES El No 0 <br />El Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br /> <br />Registration # License # Sticker # <br />l Mobile Food Prep Unit-- Make Vehicle Type Color <br /> <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />to 0 Ice Plant 0 Produce Stand <br />to 0 CFO 0 A El B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy <br />CUPA <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 (2 <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />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 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site El 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 El Out of Service Pool/Spa 0 Natural Bathing Area <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 />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 El Chemical Toilets ----Number of Units <br />0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />0 Kennel <br />Capacity Vehicle # <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 <br />Transfer Station 0 Veterinary Clinic <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (tt of Units) <br />Nursing 0 Large Generator <br />0 Common Storage Facility 0 2- 10 <br />Sludgerm <br />0 ClAkieeigii <br /> 0 Farm/Ranertiarctrop Site <br />r 0 <br />Small Gentifvfolo0 LiAte4Ifuler <br />11,; 6/31/14f4/Aenerators <br />r7 AL. AIWAlc.Utii EpAii,ro r PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON A-y,' Kix /vursoc -t, Day Phz4___ Night Ph <br />0 Surcharge FEE 0 Other FEE <br />INSPECTOR # PERMIT VALID - 2 to \2 — 2 0 Food H.aftWer <br />Check #. AMOUNT PAID I Date 51 all" INVOICE # kst Llq.IL ° <br />126 h von- REVIEWED BY <br />CNA vdrPt—IctIc+3 <br />PROGRAM ELEMENT FEE <br />48-02-034 <br />1/23/13 <br />ACCOUNTING OFFICE Date <br />MASTERFILE RECORD INFORMATION PINK