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FOOD PROGRAM (1600) <br />El Restaurant: Seating Capacity <br />CI Commissary 0 Dry storage only <br />CI Retail Market----Square footage <br />10...E1obile Food Vehicle --Make <br />Registration # <br />CI Mobile Food Prep Unit-- Make <br />Registration # <br />CI Temporary Food Facility --Dates of operation <br />Square Footage Food Handlers Course required: YES 0 No I=1 <br />0 with Food Preparation OVending Machines Number of Units <br />El w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />from to El Ice Plant CI Produce Stand <br />Vehicle Type Color <br />License # Sticker # 1.52e 7. <br />Vehicle Type Color <br />License # Sticker # <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 />CONTACT PERSON do ',VI CA Day Ph :7,2 425 7F92_ Night Ph 30.7- (,;72., 3 7f; <br />0 Surcharge FEE 0 Other FEE <br />INSPECTOR # 9 S7 PERMIT VALID q fr° h SC to 12-43111? . CI Food Handler <br />CI Check # AMOUNT P ID 4 0/b1 —. Date 1 12-0 / I ir INVOICE # 3/5517"/ <br />Cash REVIEWED BY,- ACCOUNTING OFFICE 145 Date qi,2-0 h <br />PROGRAM ELEMENT / (f7 FEE <br />SAN JOAQUIN COUNTY E IRONMENTAL HEALTH DEPAR'ENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 [Clew EH Program at Existing Facility ONew EH Program and New Facility <br />Facility ID 060242 Y q Program Record ID .?R 1: 6 2 7 i -3 7 7 , _ Facility Address c29(5/) E.- 1-717-4,4d//qt? )a v 3 1ndoecni9 9 ok5 — <br />(Please check the appropriate description and specify size, nuMber of units and pertinent information.) <br />CI Special Event---Dates of operation from to El CFO LI A I=1 B <br /> <br />DAIRY PROGRAM (2000) <br />0 Grade A Dairy CI Grade B Dairy CI Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program 0 Program 1 Facility CI Program 2 Facility CI Program 3 Facility <br />CI Hazardous Waste Generator (2200) > Tons Generated Per Year <br />CI Tiered Permitting Facility > 1:1 CA (2232) I=1 CE (2233, 2234, 2235, 2237) CI PBR (2231) 1:1 PBR HHW (2236) <br />CI Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />El 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 />El Environmental Assessment 0 UST-CAP Site CI Local HW Cleanup Site I=1 NPUSEP Cleanup Site El UIC Site <br />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 El Out of Service Pool/Spa El Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />El Poultry Farm Maximum number of birds El Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) ID Mechanical DSPS Notification (4115) CI 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 Vehicle Registration # License # <br />Pumper Yard <br /> <br />CI Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill CI Transfer Station <br />CI Waste Tire Facility CI Compost Facility <br />El Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Cl Primary Care CI Acute Care CI Skilled Nursing 0 Large Generator LI <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2- 10 <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />El Ag/Cannery Waste Site <br />CI Process/Recycle Facility <br />El Dumpsters > 20 cu yd (# of Units) <br /> Capacity Vehicle # <br />CI Chemical Toilets, ----Numberof LJPAym <br />JOAQuitv cou rx <br />a u ler <br />i,ENV/R n _rtiritt <br />Small G0MKiirtpii-0 <br />11 - 60 R-IlleArieerators <br />El Sludg <br />Rec4 <br />sEpavifill Site <br />6f;:i Farrnrkafic12018alup Site <br />1/23/13