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SAN JOAQUIN COUNTY E AMENTAL HEALTH DEPAR*. MASTERFILE RECORD INFORMATION FORM 0 New EI-1 Program at Existing Facility Sf<lew EH Program and New acuity Facility ID 7/1-,/ Program Record ID Fko6-2-/-1 7 Facility Address V01 SNicaA111-ein -6 PAYMENT RECEIVED APR 10 2017 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT (Please check the appropriate description and specify size, number of units FOOD PROGRAM (1600) CI Restaurant: Seating Capacity Square Footage Commissary 0 Dry storage only 0 with Food Preparation Retail Market----Square footage 0 w/Meat Market only Mobile Food Vehicle --Make Vehicle Type IRegistration # LYMobile Food Prep Unit-- Make Registration # &V, Temporary Food Facility --Dates of operation from CI Special Event---Dates of operation from to License # and pertinent information.) Food Handlers Course required: YES 0 No 0 OVending Machines Number of Units 0 Multiple Departments 0 Prepackaged Goods Only Color Sticker # Color Sticker # Vehicle Type ,7)iv NI o3,2,t(f2icense # Lip-5 7(mq to 0 Ice Plant 0 Produce Stand 0 CFO 0 A 0 B DAIRY PROGRAM (2000) Grade A Dairy CUPA 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit 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) CI 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) CI Hotel/Motel Number of Units CI 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 CI UST-CAP Site 0 Local HW Cleanup Site El NPL/SEP Cleanup Site El UIC Site Abandoned HW Site 0 non-NPL/SEP Cleanup Site CI RWQCB Cleanup Site CI Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility El Pool CI Spa CI Out of Service Pool/Spa CI Natural Bathing Area VECTOR CONTROL PROGRAM (4000) CI Poultry Farm Maximum number of birds TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) CI Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) El Body Art Facility-Single Use (4120) El 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 Vehicle Registration # License # Capacity Vehicle # El Pumper Yard Cl Package Treatment Plant 0 Chemical Toilets ----Number of Units CI Kennel SOLID WASTE PROGRAM (4400) CI Landfill 0 Transfer Station Waste Tire Facility CI Compost Facility CI Refuse Vehicles of Units) MEDICAL WASTE PROGRAM (4500) Primary Care 0 Acute Care CI Skilled Transfer Station 0 Veterinary Clinic El Ag/Cannery Waste Site CI Sludge/Ash Site CI Process/Recycle Facility 0 CIA Landfill Site El Dumpsters > 20 cu yd (# of Units) 0 Farm/Ranch Cleanup Site Nursing CI Large Generator 0 Small Generator CI Limited Hauler CI Common Storage Facility CI 2 - 10 0 11 - 60 0 > 60 generators 0 Other FEE ACCOUNTING OFFICE PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM -*CONTACT PERSON f,4ricy t4 1.2 •-• Day Ph 9,c 9 Night Ph ,9C9 -9,671-7 to S( Date 4-117/ ( El Food Handler INVOICE # Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13 PROGRAM ELEMENT I (0 g- FEE El Surcharg FEE INSPECTOR # q4-0)0 PERMIT VAL CI Check # AMOUNT PAIR',2/f. )D Cash REVIEWED BY Mix&