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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION F M <br />11 Ncw FH Prnnrnm at Fxistinn Facility New EH Program and New Facility <br />ID F,4(�;0 9-7+72- Program Record ID <br />Facility Address 0U9 ujo:Kylbo <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />1600) <br />RestFOFO estaurant. Seats <br />aurant: Seating Capacity Square Footage Food Handlers Course required: Yes ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle —Make <br />Vehicle Type <br />Color <br />Registration # <br />License # <br />Sticker # <br />❑ Mobile Food Prep Unit-- Make <br />Vehicle Type <br />Color <br />Registration # <br />License # <br />Sticker # <br />❑ Temporary Food Facility —Dates of operation from <br />to <br />❑ Ice Plant <br />❑ Special Event --Dates of operation from <br />to <br />❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />Produce Stand <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200) -------->-Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PBR HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel---Number of Units ❑ 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 />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm ----Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Kennel <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper VehicleRegistration # <br />❑ Pumper Yard <br />License # <br />❑ Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station <br />❑ Waste Tire Facility ❑ Compost Facility <br />❑ Refuse Vehicles I# of units) <br />Capacity Vehicle # <br />❑ Chemical Toilets —Number of Units <br />MSN <br />❑ Ag/Cannery Waste Site ❑ Sludge/As'Ht>,E/, <br />El11`�� <br />1:1Process/Recycle Facility CIA Land Site V <br />Dumpsters> 20 cu yd (#of units) ❑ FarmlRa llaquSt Site <br />MEDICAL WASTE PROGRAM (4500) 4%J0 GG !!02? <br />❑ Primary Care ElAcute Care El Skilled Nursing 11 Large Generator ❑ Small Generator jN <br />❑ Transfer Station El Veterinary Clinic ❑ Common Storage Facility 1:12 - 10 ❑ 11 - 60 ry . Uj <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form TMEAft <br />l EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON ,pilotyoxck,,GC o Day PhCIo' Night Ph 01P4)21(b I(o <br />PROGRAM ELEMENT !� FEE 11SurcharoeF E 11 Other FEE <br />INSPECTOR# D�PERMITVALID 2 t0 12"312--o ❑ Food Handler <br />c❑ heck# vt AMOUNT PAID a Date � INVOICE# <br />ash ,II,rS�.r'1li REVIEWED BY '�J(/A//CCCOUNTING OFFICE �,I Date 16 2 <br />1/2313 CNN: 1 t 44 of 1 � , r P� /� / l�—r / ASTERFILE RECORD . FORMATION PINK <br />-. u """ VVV _!'=JN'_l#- I ti(/L'� i f/l/(Wf I _{-vA <br />