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SAN JOAQUIN COUNTYlEfelll ---VIENTAL HEALTH DEPARipin MASTERFILE RECORD INFORMATION FORM '1.New EH Program at Existing Facility 0New EH Program and New Facility acility ID _____Program Record ID ?Ras-1,1,351i O2fl , Facility Address ) i ---(--favref)A()I k---C6 ,CN c3V-52., ENVIRONMENTAL JOAQUIN COUNTY (Please check the appropriate description and specify size, number of units and pertinent information.) HEALTH DEPARTMENT FOOD PROGRAM (1600) 0 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units Retail Market----Square footage Mobile Food Vehicle --Make Vehicle Type Color , .. Registration # License # -6r Sticker # 7-1t-- Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # (.(3'1.-Ci / 1 / :----"1-)c-/ Sticker # Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand Special Event---Dates of operation from to 0 CFO 0A013 DAIRY PROGRAM (2000) Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit CUPA Hazardous Materials Business Plan (1900) Number of chemicals: CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility Hazardous Waste Generator (2200) > Tons Generated Per Year Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) CI PBR HHW (2236) Aboveground Storage Tank Facility (AST) (2800) Number of ASTs Underground Storage Tank Program (UST) (2300) Use UST A and B forms Other CUPA Program HOUSING PROGRAM (2400) Hotel/Motel Number of Units 0 Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) Li Poultry Farm Maximum number of birds 0 Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) El Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) Pumper Vehicle Registration # License # Capacity Vehicle # Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) Landfill 0 Transfer Station 0 Ag/Cannery Waste Site CI Sludge/Ash Site CI Waste Tire Facility 0 Compost Facility CI Process/Recycle Facility 0 CIA Landfill Site CI Refuse Vehicles (# of Units) Li Dumpsters > 20 Cu yd (# of Units) Li Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 El 11 - 60 Li > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Fotm "EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON i4r\ N 1/2_, Day Pk2404:112--424,0 Night Ph (4j-A Ci; ILO t PAYMENT RECE WED tA 2 7 2018 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only PROGRAM ELEMENT (23 FEE 0 Surcharge EE INSPECTOR # PERMIT VALID 7(27/f to CI Check # AMOUNT PAID0, 3-7 Date dEi-Cash REVIEWED BY ACCOUNTING OFFICE 48-02-034 Other FEE Food Handler INVOICE # 3 0 ct- Se) i"-- Date 7/3 ' ir MASTERFILE RECO D IN ORMATION PINK 1/23/13