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PROGRAM ELEMENT \\Q3 FEE .OU 0 Surchar e FET Li Other FEE <br />INSPECTOR # 5 PERMIT VALID to 1=1 Food Handler <br />Li Check # AMOUNT PAID Date - INVOICE # <br />Li Cash REVIEWED BY L-AutiOi s, ACCOUNTING OFFICE ,14 Date / 7 <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Li Dumpsters > 20 cu yd (# of Units) <br />El Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />PAYMENT RECEIVED <br />FEB 1 1 2019 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />0New EH Program and New Facility <br />Facility Address \1L1 Uc\ <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br /> Square Footage Food Handlers Course required: YES 0 No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />CI Retail Market----Square footage <br /> <br />0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />4 ,IsT Mobile Food Vehicle --Make C..tAC V \Ct,,3 Vehicle Type Color CA,rer....."A <br />Mobile Food Prep Unit-- Make 5 t3 !-; 0- D, Vehicle Type Color <br />Registration # C •?.:3-kts4,0,D 331ea1itiZse # Sticker # <br />Registration # License # Sticker # <br />Li Temporary Food Facility --Dates of operation from to 0 Ice Plant Li Produce Stand <br />Special Event---Dates of operation from to El CFO 0A0B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility CI Program 3 Facility <br />Hazardous Waste Generator (2200) > Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) Li 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 CI UIC Site <br />Abandoned HW Site CI non-NPUSEP 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 />I:1 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 Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) Li Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper VehicleRegistration # License # Capacity Vehicle # <br />CI 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 1:1 Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator CI Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic CI Common Storage Facility 0 2 - 10 0 11 - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application F01711 <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />A-CONTACT PERSON cNt Day Ph 11 5 '7 1. lio"ight Ph <br />48-02-034 <br />1/23/13 5-76 1G-G3 MASTERFILE RECO D INFORMATION PINK <br />SAN JOAQUIN COUNTY EN ONMENTAL HEALTH DEPARTA <br />MASTERFILE RECORD INFORMATION FORM <br />_-New EH Program at Existing Facility <br />Facility ID GaZ.S-0/ 7 Program Record ID ?R05471q/37