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Square Footage CI with Food Preparation 0 with Meat Market only Food Handlers Course required: YES CI No CI OVending Machines Number of Units CI Multiple Departments0 Prepackaged Goods Only Vehicle Typ9._ Color License # l'41-1-1-1 2- Sticker # SAN JOAQUIN COUNTY E RONMENTAL HEALTH DEPAR :NT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility ONew EH Program and New Facility Facility ID Program Record ID -1--)K05 -/.2 Facility Address 2.-A00 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) Restaurant: Seating Capacity CI Commissary CI Dry storage only CI Retail Market----Square footage p 'Mobile Food Vehicle --Make Registration # CI Mobile Food Prep Unit Registration # License # Temporary Food Facility --Dates of operation from to CI Special Event Dates of operation from to DAIRY PROGRAM (2000) CI Grade A Dairy CI Grade B Dairy Cl Milk Dispenser-Number of Containers in Multi-Head Unit CUPA Cl Hazardous Materials Program (1900) CI Hazardous Materials Business Plan (1920, 1921) Hazardous Waste Program (2200) CI Hazardous Waste Generator Tons Generated Per Year CI Recycle/Exempt System (2299) CRT Offsite Handlers (2218) El Silver Only (2222) CI Appliance Recyclers (2217) Tiered Permitting Facility O Conditionally Authorized (CA) CI Conditionally Exempt (CE) Permit-By-Rule Fixed Unit CI Permit-By-Rule Household Haz Waste Aboveground Storage Tank Facility (AST) (2390) Number of AST CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms HOUSING PROGRAM (2400) CI Hotel/Motel Number of Units I=1 Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) CI Environmental Assessment CI UST-CAP Site CI Local HW Cleanup Site El NPL/SEP Cleanup Site 0 UIC Site CI Abandoned HW Site El non-NPLJSEP Cleanup Site Cl RWQCB Cleanup Site 0 Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility CI Pool 0 Spa CI Out of Service Pool/Spa El Natural Bathing Area VECTOR CONTROL PROGRAM (4000) CI Poultry Farm Maximum number of birds CI Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) El Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) I=1 Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) CI Pumper VehicleRegistration # License # Capacity Vehicle # CI Pumper Yard CI Package Treatment Plant CI Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) CI Landfill CI Transfer Station El Ag/Cannery Waste Site Waste Tire Facility CI Compost Facility 0 Process/Recycle Facility CI Refuse Vehicles (# of Units) El Dumpsters > 20 cu yd (# of Units) MEDICAL WASTE PROGRAM (4500) CI Primary Care CI Acute Care CI Skilled Nursing CI Large Generator 0 Small Generator CI Limited Hauler CI Transfer Station CI Veterinary Clinic CI Common Storage Facility CI 2 - 10 CI 11 - 60 CI > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form Make Vehicle Type Color Sticker # 0 Ice Plant CI Produce Stand Sludge/Ash Site CI CIA Landfill Site Farm/Ranch Cleanup Site ER ENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM Day Ph ---)192-a)j, Night Ph /L0i) -6k 367. PROGRAM ELEMENT 1,2 FEE Al?2, INSPECTOR # 621 g PERMIT VALID 3 14 CI Surcharge FEE to CI Check # AMOUNT PAID 2, ')? In Cash REVIEWED B ACCOUNTING OFFICE CONTACT PERSON NiOtAiWIA CI Other FEE Date 3ig El Food Handler INVOICE #40 M 2- Date AY/ 48-02-034 MASTERFILE RECORD INFORMATION PINK 8/21/12