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alra57 otor <br />' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />6j4ew EH Program at Existing Facility <br />Facility IDWinn-0 <br />Facility Address <br />(Please check the appropriate description and specify size, <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 # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br /> <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />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 />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 />El 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-NPLJSEP 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 />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Poultry Farm Maximum number of birds <br /> <br />1:1 "nnettECEIVED <br />PAYMENT <br />El Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single sUANs <br />EMJ A012T Y I IN I 202 <br />4 <br />1 <br />0 Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mo.bilEeNFvai:i(l)iNtym (E4N1T3A11 ) <br />LIQUID WASTE PROGRAM (4200) <br />_ <br />Pumper Vehicle Registration # License # Capacity Velittfitkali DEPARTMENT <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 O Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility O CIA Landfill Site <br />Refuse Vehicles (# of units) 0 Dumpsters >20 Cu yd of Units) <br /> <br />O Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 0 > 60 generators <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 /> <br />Day Ph Z-tt.2,0"-Cetit5.92,3Night Ph r3) 119 6,6) CONTACT PERSON .J,es,•-f c-t- <br />6,14(e-w EH Program and New Facility <br />Program Record ID ?t2240-0 2;2;2-- <br />C n jLf <br />number of units rtinent information.) <br />a t e <br />License # <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 />PROGRAM ELy1.13ENT 5 FEE 1• <br />INSPECTOR # Li PERMIT VALID <br />Check # \/ 5)AMOUNT PAID <br />El Cash REVIEWED BY <br />48-02-034 <br />kA-k <br />L , <br />1/23/13 U1/4..) r\1 D*1/1 6 ecig— - .2c) W17 <br />to <br />Date <br />ACCOUNTING OFFIC <br />Other FEE <br />Food Hiailer <br />INVOICE # <br />Date <br />MASTERFILE RECORD INFORMATION PINK <br />0 Surcharge FEE