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SAN JOAQUIN COUNTY ,....%/IRONMENTAL HEALTH DEPAR...1ENT <br />MASTERFILE RECORD INFORMATION FORM <br />El New EH Program at Existing Facility EINew EH Program and New Facility <br />Facility ID -,D Program Record ID t a 537 <br />Facility Facility Address 14), tioaci 2 f k_., 9_c 2 6 <br />(Please check the appropriate description and specify size, number dunits and pertinent information.) <br />FOOD PROGRAM (1600) <br />El Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES El No El <br />El Commissary 1E1 Dry storage only El with Food Preparation 10Vending Machines Number of Units <br />Retail Market----Square footage El w/Meat Market only El Multiple Departments El Prepackaged Goods Only <br />El Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # 2.173 <br />Mobile Food Prep Unit-- Make Vehitle Type Color <br />Registration # License # Sticker # <br />El Temporary Food Facility --Dates of operation from to El Ice Plant 0 Produce Stand <br />El Special Event---Dates of operation from to El CFO 0 A El B <br />j5g CA fk- 4 <br />DAIRY PROGRAM (2000) <br />El Grade A Dairy El Grade B Dairy( <br />CUPA <br />El Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program 0 Program 1 Facility 1:1 Program 2 Facility El Program 3 Facility <br />0 Hazardous Waste Generator (2200) > Tons Generated Per Year <br />Tiered Permitting Facility > El CA (2232) El CE (2233, 2234, 2235, 2237) El PER (2231) El PBR HHW (2236) <br />El Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />El Underground Storage Tank Program (UST) (2300) Use UST A and E3 forms <br />El Other CUPA Program <br />HOUSING PROGRAM (2400) <br />l Hotel/Motel Number of Units El Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />0 Environmental Assessment El UST-CAP Site El Local HVV Cleanup Site El NPL/SEP Cleanup Site El UIC Site <br />Abandoned HW Site El non-NPL/SEP Cleanup Site E3 RWQCB Cleanup Site El Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility El Pool El Spa El Out of Service Pool/Spa El Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds El Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />El Body Art Practitioner Reg (4110) El Mechanical DSPS Notification (4115) El Body Art Facility-Single Use (4120) <br />El Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) El Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />E Pumper VehicleRegistration # License # Capacity Vehicle # <br />El Pumper Yard El Package Treatment Plant El Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />El Landfill I: Transfer Station <br />1=1 Waste Tire Facility CI Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 1:3 Acute Care El Skilled Nursing El Large Generator <br />Cl Transfer Station 0 Veterinary Clinic <br /><77 <br />JAN 2 0 2015 <br />ENVIRONMENT HEALTH <br />PERMIT/SERVICES <br />El Small Generator El Limited Hauler <br />El Milk Dispenser-Number of Containers in Multi-Head Unit <br />E Common Storage Facility 0 2 - 10 El 11-60 0 >60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />E RGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERS, 4 Day Ph (.2 2 Z. ="11 Night Ph(?,...tcr) r7C al <br />El Surcharge F <br />to i 3/ <br />Date <br />ACCOUNTING OFFICE <br />El Other FEE <br />El Food Handler <br />INVOICE # <br />MASTERFILE REC RD INFORMATION PINK <br />Date 075-- <br />48-02-034 <br />El <br />El <br />Check # <br />cash <br />INSPECTOR # i2411/1; <br />PROGRAM ELEMENT <br />REVIEWED BY JO <br />/01 /1 <br />El Ag/Cannery Waste Site <br />El Process/Recycle Facility <br />E Dumpsters > 20 cu yd (# of Units) <br />El Sludge/Ash Site <br />El CIA Landfill Site <br />El Farm/Ranch Cleanup Site <br />1/6 3 .3 FE <br />PERMIT VALID <br />AMOUNT PAID