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CI Spa CI Out of Service Pool/Spa CI Natural Bathing Area 0 Kennel t Li r) PERMIT VALID INvoicE# Date MASTERFILE RECORD INFORMATION PINK PROGRAM ELEMENT L 2)`-t FEE INSPECTOR # CI Check # AMOUNT PAID Cash REVIEWED BY 48-02-034 0 Surchar ,? FEE CI Other FEE to I 6 0 Food Handler Date ACCOUNTING OFFICE SAN JOAQUIN COUNTY E ONMENTAL HEALTH DEPAR- 4T MASTERFILE RECORD INFORMATION FORM El New EH Program at Existing Facility KiNew EH Program and New Facility Facility ID :-/iL)c) Program Record ID 403- 4-71/ Yrryvtrn/ 71- (Please check the appropriate description and specify size, number of units FOOD PROGRAM (1600) CI Restaurant: Seating Capacity Square Footage 0 Commissary CI Dry storage only I=1 with Food Preparation ,Retail Market----Square footage CI w/Meat Market only 'Mobile Food Vehicle --Make Registration # fMobile Food Prep Unit-- Make r,,r Registration # 54 OW E-3 r"),-/e1_3(-6 3(' CI Temporary Food Facility --Dates of operation from CI Special Event---Dates of operation from to CI CFO 0 A 0 B DAIRY PROGRAM (2000) CI Grade A Dairy CU PA 0 Grade B Dairy CI Milk Dispenser-Number of Containers in Multi-Head Unit Hazardous Materials Business Plan (1900) Number of chemicals: El CalARP Program 0 Program 1 Facility CI Program 2 Facility 0 Program 3 Facility CI Hazardous Waste Generator (2200) > Tons Generated Per Year CI Tiered Permitting Facility > CI CA (2232) CI CE (2233, 2234, 2235, 2237) CI PBR (2231) CI PBR HHW (2236) CI Aboveground Storage Tank Facility (AST) (2800) Number of ASTs CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms CI Other CUPA Program HOUSING PROGRAM (2400) 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) CI Environmental Assessment CI UST-CAP Site CI Local HW Cleanup Site CI NPL/SEP Cleanup Site 0 UIC Site CI Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site CI Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility CI Pool VECTOR CONTROL PROGRAM (4000) Poultry Farm Maximum number of birds TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) CI Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) CI 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) Facility Address -9-3 i PAymzNi. RE cEivED APR 6 2017 SAN joAQu... couivry and pertinent information.) ElvviRoni4v HEALTH DEpA.,„ . Food Handlers Course required: YES 0 No 0 OVending Machines Number of Units CI Multiple Departments CI Prepackaged Goods Only Vehicle Type Color License # Sticker # Vehicle Type f=--- Color wh. ‘c //1,c1 License # h3 Sticker # r, to CI Ice Plant 0 Produce Stand LIQUID WASTE PROGRAM (4200) CI Pumper Vehicle Registration # CI Pumper Yard SOLID WASTE PROGRAM (4400) CI Landfill 0 Transfer Station CI Waste Tire Facility CI Compost Facility CI Refuse Vehicles (# of Units) MEDICAL WASTE PROGRAM (4500) CI Primary Care 1:1 Acute Care CI Skilled CI Transfer Station 0 Veterinary Clinic Capacity Vehicle # CI Chemical Toilets ----Number of Units El Ag/Cannery Waste Site CI Process/Recycle Facility El Dumpsters > 20 cu yd (# of Units) CI Sludge/Ash Site 0 CIA Landfill Site 0 Farm/Ranch Cleanup Site Nursing 0 Large Generator 0 Small Generator CI Limited Hauler CI Common Storage Facility 0 2 - 10 0 11 - 60 CI > 60 generators License # CI Package Treatment Plant PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON ,c (_ ,1( Vcfre/c/ Cerro, Day Ph (leq)3/.--617Z4, Night Ph (7,0a)S-70 Y65 c/ 1/23/13