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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM F❑New EH Program at Existing Facility Few EH Program and New Facility acility ID J5kOD2-1�17 Program Record ID D5 Facility Addre8s_� 1 . ��G �1`err r G/J 9,17 0? (Please check the approprlate description and specify ze,number of unitsand portlnent Information,) F�QD PROGjil(1600) ❑ Restaurant: Seating Capacity Square Footage�� Food Handlers Course required; Yles❑ No ❑ ❑ Commissary 0 Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market---Square footage ❑ with Meet Market only CI Multiple Departrnents0i'115'repackaged Goods Only ❑ Mobile Food Vehicle—Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit Make Registration# Vehicle Type Color _ License!� Sticker# ❑ Temporary Food Facility—Dates of operation from to ❑ Special Event Dates of operation from Ice Plant to ❑ Produce Stand FAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator----------TonsGenerated Per Year ❑ ReryclelExampt System(2299) ❑ CRT Offsite Handlers(221a) -----------❑ Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility-----....--_-....❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) CI Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use U_STA end B forms HOUSING_PROPRAM(2400) ❑ Hotel/Motel-----Number of Units C1 Jail or Exempt Institution ---Number of Units Employee Housing(2700)Use Emnlove-Housing/Labor Cams Anal t! Form RITE MITIGATION(2900) VNQERGjR0UNQ1NjECTl0N CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site 0 Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remedlatlon$Its RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area (4000) ❑ Poultry Faun-----Maximum number of birds — ❑ Kennel TATTOQ_ ODY PIERGIN. DFRMANENT^r•C-- nC ee.t a(4100) ❑ Tattooing(4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets---Number of Units SOLIDAS PROGRAM(4400) O Landfill ❑Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility C] CIA Landfill Site ❑ Refuse Vehicles 0 of Unite) ❑ Dumpsters>20 cu yd(#of units) ❑ Farm/Ranch Cleanup Site W (4500) ❑ Primary Care Cl Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limped Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATERI=M PRO-GRAM,(4600)Use PW8 EHA 46-0&003 Blue AUftodon Form Y i F CONTACT PERSON i r Day Ph YZ'W j Night Ph PROGRAM ELEMENT co ❑ Surch rge EE ❑ Other FEE INSPECTOR# PERMITVALID 2 ZDIL to i/ —7 ❑ Food Handier ❑ Check# AMOUNT PAID Date INVOICE I r� ❑ Cash REVIEWED sy ACCOUNTING OFFICE Date / Z 48.02.034 11/15/07 MARTERFILE RECORD INFORMATION PINK Received Tlme Dec. 14, 2012 1 . 23PM \1o. 3124