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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility ONew EH Program and New Facility <br />Mobile Food Prep Unit-- Make <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />D <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 1:1 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 />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 <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) El Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # <br />0 Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <br />e 6/ <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Sma4 r 0 1.1kri,d Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 thigav4,141fb& 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form k-P 47- 414. <br />lii'7-4.4( <br /> <br />EMERGENCY NOTIFICATRN FOR THIS FACILITY AND/OR PROGRAM g'747, <br />CONTACT PERSON A )4..)P,12.--i4,--or--R-Ae ..,S - V-3 '''',° Day Ph i-fOS -..”b - 210INight Ph <br />PROGRAM ELEMENT Li/ 53 FEE • 0 Surcharge FEE <br />INSPECTOR # y7 PERMIT VALID Lir 20 2& to <br />R‘is . El,ptteck# AMOUNT PAID c Date 21) <br />Lf C V1S REVIEWED BY ACCOUNTING OFFICE <br />-.1(kiLt(42 zc 04 <br />Facility ID rA 00,2:7 7 Program Record ID PR61---y-ty <br />Facility Addressv- 4[3 v \ Can M- iejr-0"\ C A 95.0 <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 Food Handlers Course required: YES 0 No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br /> Vehicle Type Color <br />License # Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />0 Kennel <br />License # Capacity Vehicle # <br />MEDICAL WASTE PROGRAM (4500) <br />0 Package Treatment Plant <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />El Dumpsters > 20 Cu yd (# of Units) <br />CI Chemical Toilets ----Number of Units <br />0 CI <br />rn/Ra <br />aq4/ <br />nup Site <br />Other FEE <br />Food Handler <br />INVOICE # <br /> cf2S- <br />Date 23 <br />48- -03 <br />1/23/13 <br />MASTERFILE RECORD INFORMATION PINK