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El Ag/Cannery Waste Site <br />0 Process/Recycle Facility <br />El Dumpsters > 20 cu yd (# of Units) <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />1 s- <br />( <br />0 Kennel <br />License # Capacity Vehicle # <br />0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br /> <br />MASTERFILE RECORD INFORMATION FORM <br />IL(2f-New EH Program at Existing Facility <br /> RECEIVED <br />SAN JOAQUIN COUNTY IIRONMENTAL HEALTH DEPAF ENT PAYMENT <br />OCT 0 1 2015 <br />Facility ID FAcy)2.-313a— Program Record ID S4NE4OvAIRQ0UIN COUNTY <br />Facility Address (100 E., 1.-1-etiK1 it)( , 4.1D.1 k1_-1-(»--) HEALTH DEPAEIRLENT <br />on and specify size, nurnher of units and pertinent information.) <br />ONew EH Program and New Facility <br />Square Footage Food Handlers Course required: YES No El <br />0 with Food Preparation OVending Machines Number of Units <br />0 w/Meat Market only Cl Multiple Departments 0 Prepackaged Goods Only <br />0/Mobile Food Vehicle --Make Vehicle Type Color <br /> <br />(Please check the appropriate descripti <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity <br />CI Commissary 0 Dry storage only <br />CI Retail Market----Square footage <br />Registration # License # Sticker # <br />:javobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # II /`,I L— S 914 Sticker # 42E-11 2--- <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant CI Produce Stand <br />Special Event---Dates of operation from to 0 CFO 0A0B <br />DAIRY PROGRAM (2000) <br />CI Grade A Dairy <br />CU PA <br />0 Grade B Dairy D Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program 0 Program I Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) > Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) El CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />CI 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 CI Local HW Cleanup Site Cl 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 CI 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 <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 />0 Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Landfill CI Transfer Station <br />CI Waste Tire Facility 0 Compost Facility <br />0 Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator CI Small Generator CI Limited Hauler <br />CI Transfer Station 0 Veterinary Clinic El Common Storage Facility 0 2- 10 0 11 -60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EME ENC NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON '1(.< 7, cie Day PricNCJ — SL,2(4.2d\light Ph a'...(ry\e.. <br />CI Surcharge FEE <br />to / 2/ <br />Date <br />PROGRAM ELEMENT FEE <br />INSPECTOR # (-6 C1 PERMIT VALID <br />0 Check # AMOUNT PAID <br />Cash REVIEWED BY <br /> ACCOUNTING OFFICE <br />0 Other FEE <br />0 Food Handler <br />INvoicE# <br />Date k) <br />MASTERFILE RECORD INFORMATION PINK <br />1723/13