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DAIRY PROGRAM (2000) CI Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit CU PA Hazardous Materials Business Plan (1900) Number of chemicals: CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 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 CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms Other CUPA Program HOUSING PROGRAM (2400) CI 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) El Environmental Assessment CI UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site CI UIC Site Abandoned HW Site El non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility CI Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) CI Poultry Farm Maximum number of birds 0 Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) El Pumper VehicleRegistration # License # Capacity Vehicle # Pumper Yard CI Package Treatment Plant 0 Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) Landfill 0 Transfer Station 0 Ag/Cannery Waste Site Waste Tire Facility CI Compost Facility 0 Process/Recycle Facility Refuse Vehicles (# of Units) 0 Dumpsters > 20 cu yd (# of Units) MEDICAL WASTE PROGRAM (4500) Primary Care CI Acute Care 0 Skilled Nursing 0 Large Generator CI Small Generator CI Limited Hauler CI Transfer Station CI Veterinary Clinic CI Common Storage Facility 0 2 - 10 CI ii - 60 CI > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form CZ4Z., % EMERGENCY NOTIF CATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph 1) S35" 25.3--3 Night Ph (1-0_ 209 ISO& PROGRAM ELEMENT PG ?)'-il) FEE _2 0 Surcharge FEE CI Other FEE INSPECTOR # PERMIT VALID /0(3 /f7 to 'ids 3 CI Food Handler 1:1 Check # AMOUNT PAID 37 - Date e iNvoicE# CI Cash REVIEWED tiY- ACCOUNTING OFFICE Date //3 / 7 CI Sludge/Ash Site 0 CIA Landfill Site CI Farm/Ranch Cleanup Site §AN JOAQUIN COUNTY EN NI )NMENTAL HEALTH DEPARTM MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility CINew EH Program and New Facility Program Record ID pkas-"i-zzci (( Facility Address 7 Lp r-i- Oa gi D and specify size, number of units and pertinent information.) Food Handlers Course required: YES No 0 CIVending Machines Number of Units 0 Multiple Departments 0 Prepackaged Goods Only Color License # 4/2 1A) 1/ 3/ Sticker # /0' Vehicle Type Color License # Sticker # to 0 Ice Plant 0 Produce Stand Special Event---Dates of operation from to CICF0 0A0B 48-02-034 MASTERFILE RE OR INFORMATION PINK Facility ID fl a3„24-3,2-2 (Please check the appropriate description FOOD PROGRAM (1600) CI Restaurant: Seating Capacity CI Commissary CI Dry storage only CI Retail Market----Square footage Square Footage CI with Food Preparation 0 w/Meat Market only Mobile Food Vehicle --Make Registration # Vehicle Type CI Mobile Food Prep Unit-- Make Registration # CI Temporary Food Facility --Dates of operation from 1/23/13