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000 2(7( rr <br />MASTERFILE RECORD INFORMATION PINK <br />60 1E- <br />; SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existin9 Facility <br />Facility ID <br />ZlNew EH Program and New Facility <br />1 Pro9ram Record ID <br />Facility Address 110 N Fl DORADO ST <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 <br />2Si Commissary 0 Dry storage only 6 with Food Preparation <br />0 Retail Market----Square footage 0 w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br /> <br />Registration # License # Sticker # <br />CI Mobile Food Prep Unit-- Make Vehicle Type Color <br /> <br />Registration # License # Sticker # <br />CI Temporary Food Facility --Dates of operation from to 0 Ice Plant CI Produce Stand <br />CI Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />CI Grade A Dairy <br />CUPA <br />CI Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit <br /> <br />CI Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility LI 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 />CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />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 />CI Environmental Assessment El UST-CAP Site 0 Local HW Cleanup Site 0 NPLISEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site D Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility CI Pool 0 Spa CI Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds LI Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />CI Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />Food Handlers Course required: YES CI No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />PAYMENT LIQUID WASTE PROGRAM (4200) <br />0 Pumper VehicleRegistration # License # <br />Pumper Yard 0 Package Treatment Plant <br /> CI Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# olUnits) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 <br />CI Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />LI Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 Cu yd (# or units) <br />Capacity Vehicle # <br />RECEIVED <br />Sludge/Ash S4*(1iG 08 2024 <br />CIA Landfgatk 41AQ U COUNTYittillTL <br />0 Farm/Ranch 04R <br />A <br /> <br />HEALTH DEPARTMENT <br />Small Generator 0 Limited Hauler <br />0 11 -60 0 >60 generators <br />1681 FEE $237.00 LI Surcharge FEE <br /> PERMIT VALID to <br />AMOUNT PAID — Date qi <br />Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> <br />CONTACT PERSON <br />PROGRAM ELEMENT <br />INSPECTOR " rr 9828 <br />Check # <br />Day Ph Night Ph <br />CI Other FEE <br />CI Food Handler <br />INVOICE #