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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />CO New EH Program at Existing Facility <br /> ID New EH Program and New Facility <br />IFacility ID VA OC ) 1 1 Ci Program Record ID 19 <br /> <br />sii.)11fr <br />Facility Address cl 1 l Q t...::) freut3er-f- Kc. 1 ccj-jialp Cci <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />CI Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES El No CI <br />El Commissary 0 Dry storage only CI with Food Preparation OVending Machines Number of Units <br />El Retail Market----Square footage CI w/Meat Market only 111 Multiple Departments 0 Prepackaged Goods Only <br />CI Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />CI Mobile Food Prep Unit-- Make Vehicle 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 CI CFO CI A 0 B <br />DAIRY PROGRAM (2000) <br />El Grade A Dairy El Grade B Dairy CI Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program El Program 1 Facility CI Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) > -Tons Generated Per Year <br />El Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) CI PBR (2231) El PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />El Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />El 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 Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Cl Environmental Assessment CI UST-CAP Site CI Local HW Cleanup Site CI NPL/SEP Cleanup Site CI UIC Site <br />Abandoned HW Site El non-NPLJSEP Cleanup Site CI RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility El Pool El Spa CI Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />El Poultry Farm Maximum number of birds Cl Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) El Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) Cl Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper Vehicle Registration # License # Capacity Vehicle # <br />CI Pumper Yard CI Package Treatment Plant CI Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill 0 Transfer Station El Ag/Cannery Waste Site CI Sludge/Ash Site <br />El Waste Tire Facility CI Compost Facility CI Process/Recycle Facility CI CIA Landfill Site <br />CI Refuse Vehicles (# of Units) CI Dumpsters > -- CU yd (# of Units) El Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care El Acute Care CI Skilled Nursing 0 Large Generator El Small Generator CI Limited Hauler <br />CI Transfer Station CI Veterinary Clinic CI Common Storage Facility CI 2 - 10 0 11 - 60 El > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />0 Surcharge FEE Cl Other FEE <br />INSPECTOR # C153 PERMIT VALID 1-1`) to Food Handler <br />El Check # AMOUNT PAID ?IAA <br />PROGRAM ELEMENT 2-2 .2 (FEE <br />Date! //)7 INVOICE # 3 52) <br />El Cash REVIEWED BY <br />48-02-034 <br />1/23/13 - <br />ACCOUNTING OFFICE Date <br />MASTERFILE RECO D INFORMATION PINK