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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTER FILE RECORD INFORMATION FORM <br />0 New EH Pro ram at Existin Facilit <br />Facility ID , Program Record ID <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 0 Commissary 0 Dry storage only 0 with Food Preparation :Wending Machines Number of Units 0 Retail Market----Square footage <br />Mobile Food Vehicle --Make 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Vehicle Type <br />License # <br />Color <br /> <br />Registration # <br />Sticker # 0 Mobile Food Prep Unit-- Make Vehicle Type <br /> <br />Registration # License # Sticker <br />Color <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand 0 Special Event---Dates of operation from to 34 CFO XA 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: 0 CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility 0 Hazardous Waste Generator (2200) >- Tons Generated Per Year <br />01* <br />0 Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) 0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms 0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />0 Hotel/Motel Number of Units 0 Jail or Exempt Institution ----Numl*er of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form P AY Nit 14 I SITE MITIGATION (2900)UNDERGROUND FC INJECTION CONTROL (300 ENED g— - <br />0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/IS%Cptaepge 0 UIC Site 0 Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site ArMo WaYer Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) onclk-oc°u‘sal Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/ \i`TEr'''ELIa4ir"-"N'atural Bathing Area VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />O Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />0 Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # Capacity Vehicle # 0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site 0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site 0 Refuse Vehicles (# of Units) 0 Dumpsters > 9n <br /> <br />..... Cu yd (# of Units) 0 Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler 0 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 END 46-02-003 Blue Application Form <br />ERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Ma r) Day Ph 90-01" OTTFT:light Ph <br />Mo <br />.5 LID q• to 0 Food Handler 0 Check # \i iS Pt AMOUNT PAID tf / Date INVOICE # <br />MASTERFILE RECORD INFORMATION PINK <br />2- a <br />Facility Address 172.41-2- 3 WOW Lahn)Pt CA c 0 <br />ONew EH Pro ram and New Facility <br />PERMIT VA <br />0 la PROGRAM ELEMEL t, FEE <br />INSPECTOR # <br />0 Cash REVIEWED BY PH Date 2 s7/3.4:7„2 ACCOUNTING OFFICE <br />0 Surch rge FEE 0 Other FEE <br />48-02-034 <br />1/23/13 <br /> <br />ig6113 (1-z 31' <br /> <br />W2V