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SAN JOAQUIN COUNTY E ONMENTAL HEALTH DEPART VT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility 0New EH Program and New Facility Facility ID —14 Program Record ID 0 Facility Address I I tIviA (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 Commissary 0 Dry storage only 0 with Food Preparation EVending Machines Number of Units Retail Market----Square footage LI w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only Mobile Food Vehicle --Make Vehicle Type Color Registration # License # Sticker # jZ3 Mobile Food Prep Unit-- Make !-:--klie"AtT-t-i_ Vehicle Type I Color Registration #_1(vt&C61 2c-F247-7 11-2i..45,43‘c License # Li1 CC= Sticker # G Temporary Food Facility --Dates of operation trom to 0 Ice Plant 0 Produce Stand Special Event---Dates of operation from to OCF0 0A0B DAIRY PROGRAM (2000) Grade A Dairy CUPA 0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit Hazardous Materials Business Plan (1900) Number of chemicals: LI 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) LI CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 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) LI Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 U1C 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 El Out of Service Pool/Spa 0 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) El Poultry Farm Maximum number of birds 0 Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) 0 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 0 Sludge/Ash Site Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site Refuse Vehicles (# of Units) LI Dumpsters > 20 cu yd (# of Units) 0 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 0 11 - 60 0 > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON (..),)Q(„4(--J Day Ph 'S 11,-C Night Ph -2 PROGRAM ELEMENT LO ./1-') FEE _411-F-77 0 Surcharge FEE 0 Other FEE INSPECTOR # 4 i -70 PERMIT VALID 77 9.-7 ii to 3't P-c c'(9 ( S-- 1:1 Food HandlerZ; - ,•• C.' '-`,..' * it,''' ,i _ . -•\• .....,„ ,..;-, AMOUNT PAID k ik , C9 L.7 Date INVOICE # 6 i(-.4(r •S.Z," -2" 0 Cash REVIEWED BY ACCOUNTING OFFICE Date 7 48-02-034 MASTERFILE REC RD INFORMATIO 1123/13