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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION F RM <br />New EH Program at Existing Facility ew EH Program and New Facility <br />Facility ID Program Record ID 5— 2(.6 <br />Facility Address 602 0 I 001 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # 4 T (c) 4 03 <br />Mobile Food Prep Unit-- Make 11-10 I) e-fz TriIciC Vehicle Type Trial ler <br />Registration # Y-TP4403 <br /> License # c cr7&o2 <br />Temporary Food Facility --Dates of operation from to <br />Special Event---Dates of operation from <br />DAIRY PROGRAM (2000) <br />El Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />LI CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 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 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 />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />El 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 # <br />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 <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />El Other FEE <br />0 Food Handler <br />Date <br />MASTERFILE RECORD I FORMATION PINK <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br /> Color <br />Sticker # <br />Color m cf._ <br />Sticker # <br />0 Ice Plant 0 Produce Stand <br />to <br />0 CFO 0 A 0 B <br />PA ym, 0 Sludge/Ash r ... <br />0 CIA Landfill Si ‘0.t./Imr,,, <br />El Refuse Vehicles (4 of Units) 0 Dumpsters > 20 cu yd (4 of Units) El Farm/Ranc,Pearm Siftiat <br />MEDICAL WASTE PROGRAM (4500) I i 2023 <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 1* ler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 -60 tirk . Vt9444/ivry <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 J ay flcl Cu c e Day Ph -5-1 0 301..613sD Night Ph .5-10 3 0 4 41 5 CO <br />PROGRAM ELEMENTi 33 FEE - 1 7-- <br />of 0 Surcharge FEE <br />INSPECTOR # )1.- L- PERMIT VALID 2t23 to 12- 51 23 <br />0 2heck # AMOUNT PAID Ng Date 9— 3 INVOICE # O 7 <br />gCash 41 REVIEWED BY ACCOUNTING OFFICE W3-1-X <br />48-02-034 <br />1/23/13