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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />CI New EH Pro ram at Existing Facilit EINew EH Program and New Facility <br />Facility ID Program Record ID <br />Facility Address ,-4-45 ,c.„—t----.1k -nmk J,;'{ .4 HI i i,i ft.( (‘ f--) (ft")/iii- <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />CI Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ID No 0 0 Commissary 0 Dry storage only CI with Food Preparation ['Vending Machines Number of Units El Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments CI Prepackaged Goods Only <br />CI Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />0 Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />0 Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />0 Special Event---Dates of operation from to 0 CFO lici A 0 B <br />DAIRY PROGRAM (2000) <br />CI Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit <br />CUPA <br />0 Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />CI Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />CI 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 />CI 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 NFUSEP Cleanup Site CI UIC Site <br />0 Abandoned HW Site El non-NPL/SEP Cleanup Site CI RWQCB Cleanup Site CI Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility CI Pool CI Spa CI Out of Service Pool/Spa CI 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) CI Body Art Facility-Single Use (4120) <br />CI Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper Vehicle Registration # <br />CI Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill CI Transfer Station <br />CI Waste Tire Facility CI Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br /> License # Capacity Vehicle # <br /> <br />CI Package Treatment Plant CI Chemical Toilets ----Number of Units <br />Day Ph , Night Ph <br />0 Sludge/Ash 11)44)11ft. <br />CIA Landfill ffkbz,. <br />Farm/Ranch CiearuFaito <br />41444 „e n <br />0Slaitnjkd Ha die r?024 <br />su , <br />/*/ 0447- 'TY <br />R r4,64, <br />El Ag/Cannery Waste Site <br />CI Process/Recycle Facility <br />El Dumpsters > 20 Cu yd (# of Units) <br />Primary Care CI Acute Care 0 Skilled Nursing CI Large Generator <br />CI Small Generator <br />CI Transfer Station CI Veterinary Clinic CI Common Storage Facility 0 2 - 10 <br /> <br />CI 11 - 60 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON 4-'71`--D) <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />PROGRAM ELEMENT - FEE 0 Surcharge FEE 0 Other FEE <br />INSPECTOR # <br />PERMIT VALID to 0 Food Handler <br />Check # <br />AMOUNT PAID <br />Date INVOICE # <br />Cash REVIEWED BY <br />ACCOUNTING OFFICE <br />Date <br />48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13