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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT REQ MEN MASTERFILE RECORD INFORMATION FORM E�VFD EH Pr n1 at ExIsting Facility ❑New EH Program and New Facility �V� Ft�l 1D _ Program Record IDo �r� ZD�� kc Facility AddressDep fArgL T (Please Check the aippropriate description and specify size,number of units and pertinent informaflon.) �Rr4F4; E R� 116p0} RO1tti4riltit flesting Capacity Square Footage Food Handlers Ccursa mciolrad; YEs I7 PID CJ ❑COmmtsaary 17 Ory storage only ❑with Foal Preparation ❑Vending Machines Number of Units 13 Raw IA *st--,Square foal e ❑w/Meat Market only ❑Mulliple Departmer:s El Prepm.kaged Goods Only Mobile Food Vehicle—Make ' �� Vehicle TypeISL( 1 ColorA _ Registration ti 1 I License#� Sticker# 0 Mobile Food Prep Unit—Make Vehicle Type _ Color Registration# License» _ _ _ Sticker#_ 0 Temporary Fend Facility--Dates of operation from !o _ ❑Ice Plant❑Produce Stand 0 Special Event--0ates of operation from to ❑CFO ❑,1❑B QAEI 822BBM(2.000) 0 Grade A Dalry ❑Grade B Dalry ❑Milk Dispenser `lumber of Containers in Mulli-Head Unit CUPA ❑Hazardous Materials Business Plan(1900) Number of chemicals ❑CaIARP PrtKlram ❑Program 1 Facility ❑Program 2 Facility ❑Program 3 Facility ❑Hazardous Waste Generator(22D0)--> Tons Generated Per Year ❑Tiered Permitting Facility--> ❑CA(2232) OCE(2233,2234,223.5,2237) OPER(222311) ❑FBR HHW(2236) I❑Aboveground Storage Tank Facility(AST)(2800) Number cf ASTs 0 Underground Storage Tank Program(UST)(2300)Use UST A,and B forms ❑Other CUPA Program HOUSING PROGRVtN(2400) — ❑Hctni!)atotel----Number of Units ❑Jail or Exempt Institution---Numter of Units Employee Housing(2700)U;r Emplovee Hcusinc.Laticr Camp Apolic anion Forth SrTE MM(jAT10lt(2900) u•:-cR R iN iN,JE(' r�N CONTROL(3000) ❑Environmental Assessment O UST-CAP Site _"Local HW Cieanup Site ❑NPUSEP Cleanup Site ❑UIC Sita ❑Abandoned HW Site ❑non-NPUSEP Cicar.up Site ❑R1h'CCB Cleanup Site ❑Water Quality Remediaticn Site RECREATIONAL lj9AL7H PROGRAM(360CJ Number of PoolslSpas at Faub!y_ ❑Fool ❑ Spa ❑Out of Semite PocllSpa ❑Natural Bathing Area VECTOR CONTROL PROGRAM(40001 ❑PoultryFarm--Maximum r:urobcr of bids _ ❑Kennel TTODA00Y PIEFCINPERLIANENT COSN TIC PROGRAM(4100) ❑Body ArtPractitioner Reg(411C) ❑Mechanical DSPS Notification(4115) ❑Body Art Facility-Single Use(41'0) ❑Body Art Facility-Sterilizatlon(4121) ❑Body Art Temp Event Co-erd(4130) ❑Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PRCjgRAM(4200) ❑Pumper VehlcleRegislration# License# _ Capacity aleh cie 0 Pumper Yard ❑Package Treatment Plant ❑Chemical Toilets---Number o1 Units SOLID WA5TE PROIIfa IAM(4400) 0 Landfill ❑Transfer Station ❑AS.Cannery Waste Site ❑SludgelAsh Site Cl Waste Tire Facility El Compost Facility G Process/Recycle Facility ❑CIA Landfill Site O Refuse Vshiciee is or unds) ❑ Dumpsters>20 cu yd,a rf uresl__ ❑FarmlRanch Cleanup Site MEDICAL WASTE PF QURAM(4500) 0 Primary Care ❑Acute Care ❑Skilled Nursing ❑ Large Generator ❑Small Generator D Limited Hauler ❑TransfsrShitlorr ❑Veterinary Clinic ❑Common Storage Facility ❑2-10 ❑ 11-60 Cl>60 generators PUBLIC WATER SYS rL'M PROGRAM(4600)Use PWS EHD 46-02-003 Blue Applicatlon Form EMERGENCY NorIFICATrO.4 FOR THIS FACILITY ANDICR PROGRAM CONTACT PERSON_ Day Ph_ N y�-4 Ph PROGRAM ELEMENT FEE _ ❑ Surcharge Fee ❑Other FEE IMsmToR# PF-RMIT VALID to--- [I Food Handler C7 t wda 0 —_ AMOUNT PAID Date _ INvolc :• - --- — -- Cash REVIEWED BY RCCOUNTING OFFICE Date f602 C�1 t/�l1111 h'ASTEFFIIcFEiCFD NrCRAWT40NPINK