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New EH Program at Existing Facility <br />Facility ID <br />IXINew EH Program_ land New Facility <br />Program Record ID e 105-It 91- <br />Food HanAl,r <br />INvoicE # 3-blo 1 6 1<- <br />ASTERFILE FkCORd INFORMATION PINK <br />Date 72,0 2,3 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility Address 678 N WILSON WAY <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />El Restaurant: Seating Capacity Square Footage <br />Commissary 0 Dry storage only <br /> 0 with Food Preparation <br />El Retail Market----Square footage 301 -2000 <br />w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments ID Prepackaged Goods Only <br />Color <br />Registration # License # <br />Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />0 Temporary Food Facility --Dates of operation from <br />Sticker # <br />Color <br />Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to OCF0 0A0B <br /> <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />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 />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 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 />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 Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units MENT <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash §i!?. <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill441 0 5 <br />Refuse Vehicles (# of Units) 0 Dumpsters > 20 cu yd (# of Units) 0 Farm/Rgmh,Cleanup <br />ENvRN MEDICAL WASTE PROGRAM (4500) <br />o Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator Lt —ETIVI 3fPW7AL <br />couNry <br />O Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2- 10 0 11 -60 0 > 60 generagMENT <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM 04) <br />CONTACT PERSON Nfikell 4.)77T1 Day Ph y Night Ph 37 <br />Other FEE <br />Check # AMOUNT PAID Date '5 2 <br />vi54 REVIEWED BY ACCOUNTING OFFICE (WO- <br />41 /82-30/21-3034 cm <br />PROGRAM ELEMENT 1615 FEE $275 <br />iNSPECTOR # 9828 PERMIT VALID 62 5123 <br />Surcha ge F E <br />to ▪ 2H