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SAN JOAQUIN COUNTY El ONMENTAL HEALTH DEPART! IT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility 'New EH Program and New F cility <br />Facility ID t4acn*S1`./ Program Record ID <br />0 Facility Address 200r) C)f\rleY irke'n CT -o TYrAr L4 CA 5 37 c <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES CI No 121 <br />Commissary 0 Dry storage only 0 with Food Preparation EVending 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 />C Le . Registration # License # Sticker # I ie <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to 0 CFO CIAO'S <br />DAIRY PROGRAM (2000) <br />El Grade A Dairy CI Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />1E1 Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program CI Program 1 Facility ID Program 2 Facility 0 Program 3 Facility <br />0 Hazardous Waste Generator (2200) > Tons Generated Per Year <br />Tiered Permitting Facility ------> 0 CA (2232) El CE (2233, 2234, 2235, 2237) 0 PBR (2231) 111 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />1E1 Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />CI Hotel/Motel Number of Units 0 Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housinq/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />1E1 Environmental Assessment CI UST-CAP Site El Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />0 Abandoned HW Site CI 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 El Pool I: Spa ri Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />0 Poultry Farm Maximum number of birds CI Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI 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 />CI Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 1E1 Chemical Toiletk----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill Cl Transfer Station 1E1 Ag/Cannery Waste Site 0 Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (// of Units) El Dumpsters > 20 cu yd (# of units) El FarmiNkiNtwit Site <br />MEDICAL WASTE PROGRAM (4500) <br />IJOI!AQ9U444rEIN COU:r <br />0 Primary Care CI Acute Care 0 Skilled Nursing ID Large Generator 0 Small Generator <br />El Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 2 - 10 0 11 - 6011 OrciNe :tors <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form 2Nritiir E Z:0.18 <br />MERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />P CONTACT PERSON nO 0 Day Ph (_20q 3(T--ight Ph <br />NT <br />PROGRAM ELEMENT \ \c).S4 FEE A kZ) 0 Surcharge FEE 0 Other FEE <br />INSPECTOR # t'tS c;\ PERMIT VALID CI i 55. to 124 CC • 0 Food Handler <br />1Check # /0 5- • AMOUNT PAID 4 lol . Date '1 /2-0// • INVOICE # <br />Cash REVIEWED BY ACCOUNTING OFFICE W ) Date et /I • <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />1/23/13