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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility 0New EH Program and New Facility Facility ID FA OOt 61Thlt.o Program Record ID GeR 2.41---oo Facility Address 2---71 "Frey' cV‘ (cirvi,10 Z t -Fre,,vm cm„„,t, cAr e) 5 2 51 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) 0 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 0 Commissary LI Dry storage only 0 with Food Preparation OVending Machines Number of Units 0 Retail Market----Square footage LI w/Meat Market only LI Multiple Departments 0 Prepackaged Goods Only Mobile Food Vehicle --Make Vehicle Type, Color Registration # License # VI t I "7--(40 Sticker # 0 Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License It Sticker It LI Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand 0 Special Event---Dates of operation from to 0 CFO 0 A 0 B DAIRY PROGRAM (2000) El Grade A Dairy 0 Grade B Dairy LI Milk Dispenser-Numberporfog rContainers Program 3 F a ini Multi-Head i7. !irrti 40) CUPA HAY n 7 v LI Hazardous Materials Business Plan (1900) Number of chemicals: IVII/ftlym.Airk749 LI CalARP Program D Program 1 Facility El Program 2 Facility 0 m LI Hazardous Waste Generator (2200) > Tons Generated Per Year Tiered Permitting Facility 0 CA (2232) CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (22'314' S D Aboveground Storage Tank Facility (AST) (2800) Number of ASTs Underground Storage Tank Program (UST) (2300) Use UST A and B forms LI Other CUPA Program HOUSING PROGRAM (2400) LI Hotel/Motel Number of Units 0 Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) El Environmental Assessment LI UST-CAP Site D Local HW Cleanup Site 0 NPL/SEP Cleanup Site El UIC Site LI Abandoned HW Site 0 non-NPLISEP Cleanup Site 0 RWQCB Cleanup Site D Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility 0 Pool 0 Spa 0 out of Service Pool/Spa 0 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) Poultry Farm Maximum number of birds 0 Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) D Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) LI Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) LI Pumper VehicleRegistration # License # Capacity Vehicle It Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) LI Landfill 0 Transfer Station LI Ag/Cannery Waste Site 0 Sludge/Ash Site Waste Tire Facility 0 Compost Facility D Process/Recycle Facility 0 CIA Landfill Site 0 Refuse Vehicles (# of Units) 0 Dumpsters > 20 cu yd of units) 0 Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) LI Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator D Small Generator 0 Limited Hauler CI Transfer Station LI Veterinary Clinic 0 Common Storage Facility 0 2-10 0 11 -60 0 >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application POUT) , EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON 2()CZY1.4C; \fel t Day Ph 201 271 .4154\light Ph WO - 2S7't/413-7" PROGRAM ELEMENT (.0 511, FEE INSPECTOR It PERMIT VALID Check # AMOUNT PAID Cash REVIEWED BY LI Surchar e FE LI Other FEE to 3 2- 0 Food Handler Date INVOICE# ACCOUNTING OFFICE Date 72-41 MASTERFILE RECORD INFORMATION PINK 48-02-034 1/23/13