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MER ENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />Da Ph 2 1.10 ‘S-OD Night Ph C2-006&O - TOO CONTACT PERSON <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd of units) <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />SAN JOAQUIN COUNTY E .RONMENTAL HEALTH DEPAR1 .NT <br />MASTERFILE RECORD INFORMATION FORM <br />OINew EH Program at Existing Facility <br />RDSZAZ)3D <br />Facility Address /Z6700 I Halidilla \V it.) SiOCkfon <br />h <br />19- `i C <br />(Please check the appropriate description and specify ' e, numb r of units and pertinent information.) <br />Square Footage Food Handlers Course required: YES 0 No 0 <br />0 with Food Preparation OVending Machines Number of Units <br />0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br /> Vehicle Type <br />Registration # License # ef Mobile Food Prep Unit-- Make G-7 V cr Vehicle Type <br />zT1Y-714 Registration # )-1(.11F2V tg 2-D IM)102b0b License # li <br />0 Temporary Food Facility --Dates of operation from to <br />Special Event---Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <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 />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-NPUSEP 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 />Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />El Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of units) <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 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />PROGRAM ELEMENT FEE 0 Surcharge FEE <br /> <br />0 Other FEE <br /> <br />INSPECTOR # PERMIT VALID 7 /( 7 to 7 / // 0 Food Handler <br />Check # AMOUNT PAID ?' Date -7 3 f7 INvo)cE# <br />ACCOUNTING OFFICE <br />MASTERFILE RE •ORD INFORMATION PINK <br />FOOD PROGRAM (1600) <br /> <br />0 Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br />Facility ID FA00,23 Program Record ID <br />ONew EH Program and New Facility <br />SAN JOAQUIN COUNTY <br />()OVIRONMENTAL <br />'5 4-- r-IDIALTH DEPARTMENT <br />Color <br />PAYMENT <br />RECEIVED <br />U3HL 2017 <br />Sticker # <br />Color <br />Sticker # <br /> 0 Ice Plant 0 Produce Stand <br />0 CFO 0 A 0 B <br />0 Kennel <br />License # <br />0 Package Treatment Plant <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />0 11 - 60 0 > 60 generators <br />48-02-034 <br />1/23/13 <br />Cash REVIEWED BY Date -47