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Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (# of Units) <br />Sludge/Ash Site <br />CIA Landfill Site <br />ED Farm/Ranch Cleanup Site <br />SAN JOAQUIN COUNTY a IONMENTAL HEALTH DEPARTP 'T <br />MASTERFILE RECORD INFORMATION FORM <br />XNew EH Program at Existing Facility <br />0New EH Program and New Facility <br />Facility ID F-A00.2_27g3 Program Record ID ?/21.)5 (kYVO <br />Facility Address 2wnrc 1L v SG 0 -5i)/P_P/16 Cfr <br />agggigg <br />MAY 0 3 2016 <br />ENVIRONMENT HEALTH <br />PERMIT/SERVICES <br />(Please check the appropriate description and specify size, <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />JO-Mobile Food Vehicle --Make <br />number of units and pertinent information.) <br />Square Footage <br />0 with Food Preparation <br />0 w/Meat Market only <br />Vehicle Type <br />Registration # License # g,--ra ,D,...24-5" Sticker # 3 41 4' (9 <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />Food Handlers Course required: YES 0 No 0 <br />0Vending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />DAIRY PROGRAM (2000) <br />[2 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 > [2 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 U1C Site <br />Abandoned HW Site 0 non-NPLJSEP 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 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Arf 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 # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />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 CI 11 -60 0 >60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph Night Ph CONTACT PERSON <br />ll . . , , PROGRAM ELEMENT I ) ,) FEE li,.(\ v((t' -P-I--' ..< ) L) 0 Surcharge FEE 0 Other FEE <br />INSPECTOR # ' ' PERMIT VALID tr(S //g to /?/3 (/( 6 0 Food Handler <br />Check # AMOUNT pAID F.„x-t,w\p 1\ Date INvacE # <br />/, 0 Cash REVIEWED BY, II" ACCOUNTING OFFICE dd52- Date <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />1/23/13