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SAN JOAQUIN COUNTY E ONMENTAL HEALTH DEPART JT MASTERFILE RECORD INFORMATION FORM apPA YMENT New EH Program at Existing Facility ONew EH Program and New Facility riecEive., Facility ID FA 00.23 2-3 'fr Program Record ID FILDS-41:6 2-0_ DEC 0 1 201;# SAN Facility Address joitQui NN Eivvilio N (Please check the appropriate description and specify size, number of units and pertinent information.E) -ALTH 04E couNrvAmiL — FOOD PROGRAM (1600) '-- 11/341E.ivr 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 0 w/Meat Market only 0 Multicle Qepartments 0 Prepackaged Goods Only [54 Mobile Food Vehicle --Make A *2-TEY Vehicle Type 4 Color ki i—b Registration #4/E)5141)Z2F190 -3-tAPLicense # 4 W:74414 Sticker # Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand Special Event---Dates of operation from to 0 CFO 0 A 0 B DAIRY PROGRAM (2000) Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit CU PA 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) 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) Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site Abandoned HW Site 0 non-NPLJSEP 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) 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 VehicleRegistration # 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)0 ')o U nrn Storage p S t B rS > 0 u d 0 (# if .0 Un its) 0 Farm/Ranch C leanup Site MEDICAL WASTE PROGRAM (4500) ry Prima Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler Transfer Station 0 Veterinary Clinic 0 Comm 2Faccilityy 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 . A CONTACT PERSON1 • Day Ph --77 ,r, 7 Night Ph -1-1S -7 (-- 8 ri PROGRAM ELEMENT k (-0,11 EE CO 0 Surcharge FEE INSPECTOR # 11+2,0 PERMIT VALID to 7 3/ .... 0/Check # / 3 !, Am TPAl c 3,Oc Date / AT C— 'E:l Cash REVIEWED BY ACCOUNTING OFFICE al Date /Y.-05- Other FEE Food Handler INvoicE#2 2 5 - (67 I 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13