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PERMIT VALID . 1/1 I I to <br />AMOUNT PAID • Date <br />ACCOUNTING OFFICE <br />PROGRAM ELEMENT 3 C., FEE C 0 Surcharge FEE <br />INSPECTOR # <br />Check # <br />,Cash <br />0 Other FEE <br />0 Food Handler <br />INVOICE US/ <br />Date REVIEWED BY <br />PAYMENT <br />RECEIVED <br />JAN 1 1 2010 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEN1 <br />• <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existittg Facility New EH Program and New Facility <br />Facility ID <br /> <br />;"\7- AMPS 9-(1),(r;) Program Record ID <br /> cr <br />I I <br />Facility Address -7 ILE L) LT- -C-7-A 7 iJ (,, CA .._g3S <br />(Please Check the appropriate decription and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity <br />El Commissary 0 Dry storage only <br />0 Retail Market --Square footage <br />p(.Mobile Food Vehicle Make (4)q.7 <br /> <br />Registration # b-1g., 3 i <br />0 Mobile Food Prep Unit—Make Vehicle Type <br />Registration 0 License # <br />ID Temporary Food Facility—Dates of operation from to <br />0 Special Event —Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy <br /> 0 Milk Dispenser—Number of Containers in Multi-Head Unit <br />CUPA 0 State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />0 Hazardous Waste Generator Tons Generated Per Year 0 Recycle / Exempt System (2299) <br />D Appliance Recyclers (2217) 0 CRT Offsite Handlers (2218) 0 Silver Only (2222) <br />CI Conditionally Exempt (CE) Tiered Permitting Facility El Conditionally Authorized (CA) <br />0 Permit-By-Rule Fixed Unit 0 Permit-By-Rule Household Hazardous Waste <br />0 ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br />1:1 Hotel/Motel —Number of Units 0 Jail or Exempt Institution —Number of Units <br />Employee Housing (2700) Use Employee IfousinKabor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />0 Environmental Assessment 0 UST-CAP Site 0 Local IIW Cleanup Site 0 NPUSEP Cleanup Site 0 1.11C Site <br />0 Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site CI Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />El Out of Service Pool/Spa Number of Pools/Spas at Facility 0 Pool 0 Spa <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Tattooing (4121) 0 Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle—Registration # License tt Capacity <br />Chemical Toilets 0 Package Treatment Plant 0 Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Ag / Cannery Waste Site 0 Transfer Station <br />0 Process/Recycle Facility 0 Compost Facility <br />Dumpsters >20 Cu yd —Number of Units <br />0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility-1: 2 - 10 —0 11 - 60 --LI > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PIES MD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON -TA11-1 .II A.) t Day Ph F ottt Night Ph <br />C_c_) <br />Square Footage <br />El with Food Preparation <br />with Meat Market only <br />Vehicle Type <br />License # T5 ••,-( k-t 5' 4- 7 <br />Food Handlers Course required: YEs 0 N <br />0 Vending Machines —Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />6-14- Color Lk) rriE <br />Sticker # D <br />Color <br />Sticker 0 <br />0 Ice Plant <br />0 Produce Stand <br />ED Natural Bathing Area <br />0 Kennel <br />0 Permanent Cosmetics (4122) <br />Vehicle 0 <br /> Number of Units <br />Landfill <br />0 Waste Tire Facility <br />ID Refuse Vehicles —Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing <br />El Sludge/Ash Site <br />0 CIA Landfill Site <br />0 Farm/Ranch Cleanup Site <br />4