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Other FEE Food Handler INvoiCE# Date El Surcharge FEE to - Date ACCOUNTING OFFICE FEE PERMIT VALID / 2.. AMOUNTPAID PROGRAM ELEMENT INSPECTOR # 6:1 32 i74 Check # 2,4 r)-- Cash REVIEWED BY SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM CI New EH Program at Existing Facility Chew EH Program and New Facility , — Facility ID 041)11 42 L Program Record ID Facility Address 2-°1 DO -E1 H---A{Cl \,\)(1 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) Restaurant: Seating Capacity Square Footage Commissary 0 Dry storage only 0 with Food Preparation Retail Market----Square footage El w/Meat Market only R./Mobile Food Vehicle --Make Vehicle Type DAIRY PROGRAM (2000) Grade A Dairy CUPA 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit CI Hazardous Materials Business Plan (1900) Number of chemicals: CalARP Program 0 Program 1 Facility El Program 2 Facility CI Program 3 Facility Hazardous Waste Generator (2200) >-Tons Generated Per Year Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) Aboveground Storage Tank Facility (AST) (2800) Number of ASTs Underground Storage Tank Program (UST) (2300) Use UST A and B forms Other CUPA Program HOUSING PROGRAM (2400) ID Hotel/Motel Number of Units 0 Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site Abandoned HW Site 0 non-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) Poultry Farm Maximum number of birds CI Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Us t acuity (4131) Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobil (4131)i LIQUID WASTE PROGRAM (4200) Pumper Vehicle Registration # Pumper Yard SOLID WASTE PROGRAM (4400) CI Landfill 0 Transfer Station Waste Tire Facility 0 Compost Facility Refuse Vehicles (# of Units) MEDICAL WASTE PROGRAM (4500) CI Primary Care CI Acute Care 0 Skilled Nursing CI Large Generator CI Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 CA r 2_3S Food Handlers Course required: YES 0 No 0 OVending Machines Number of Units 0 Multiple Departments CI Prepackaged Goods Only Color Registration # License # 2 -17 54 1-2_ Sticker # Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand Special Event---Dates of operation from to 0 CFO 0 A 0 B PAYMENT License # 0 Package Treatment Plant El Ag/Cannery Waste Site CI Process/Recycle Facility El Dumpsters >20 cu yd (# of Units) Capacity Vehicle CI Chemical Toilets ----Number of Units sAN JOAQUIN L,OUN EINMRONMENTAL HEALTH DEPARTMEN 0 Sludge/Asn bite CIA Landfill Site Farm/Ranch Cleanup Site PFc 19 20 9 0 Small Generator CI Limited Hauler 2-10 CI 1 1 - 60 CI >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EME GENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM 6\142 2 3-- '1'>i CONTACT PERSON I ApDay Ph2Oil- 21 (.()-1 1-1S Night PhZA:A - 2-1 stL•IF 5 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13 3-Lci.04- 4 2-kik