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CI Other FEE El Food Handler INVOICE # 2-3773 Date 7 / 7 El Surchar e FE to Date ACCOUNTING OFFICE SAN JOAQUIN COUNTY E RONMENTAL HEALTH DEPART NT MASTERFILE RECORD INFORMATION FORM CI New EH Program at Existing Facility 0New EH Program and New Facility Facility ID F74602-3-301 Program Record ID FRAS-414ev/6 Facility Address 2 2.49 L. • .--e-t11-e rY-1- M r1 Ur\ (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES CI No CI CI Commissary 0 Dry storage only El with Food Preparation Eh/ending Machines Number of Units Retail Market----Square footage Cl w/Meat Market only CI Multiple Departments CI Prepackaged Goods Only Mobile Food Vehicle --Make Vehicle Type 1-1171G2.2-- Color Registration # License # Sticker # CI Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # CI Temporary Food Facility --Dates of operation from to Cl Ice Plant CI Produce Stand Special Event---Dates of operation from to CI CFO 0 A 0 B DAIRY PROGRAM (2000) CI Grade A Dairy CI Grade B Dairy Cl Milk Dispenser-Number of Containers in Multi-Head Unit Cu PA CI Hazardous Materials Business Plan (1900) Number of chemicals: El CalARP Program CI Program 1 Facility CI Program 2 Facility 0 Program 3 Facility CI Hazardous Waste Generator (2200) > Tons Generated Per Year CI Tiered Permitting Facility > Cl CA (2232) El CE (2233, 2234, 2235, 2237) El PBR (2231) El PBR HHW (2236) El Aboveground Storage Tank Facility (AST) (2800) Number of ASTs CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms 1:1 Other CUPA Program HOUSING PROGRAM (2400) Hotel/Motel Number of Units Cl 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 Cl UST-CAP Site Cl Local HW Cleanup Site CI NPL/SEP Cleanup Site El UIC Site El Abandoned HW Site El non-NPL/SEP Cleanup Site El RWQCB Cleanup Site El Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility 0 Pool El Spa CI out of Service Pool/Spa 0 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) CI Poultry Farm Maximum number of birds CI Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) El Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) 1:1 Body Art Facility-Single Use (4120) CI Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) El Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) El Pumper Vehicle Registration # License # Capacity Vehicle # CI Pumper Yard El Package Treatment Plant El Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) El Landfill CI Transfer Station Cl Ag/Cannery Waste Site CI Sludge/Ash Site El Waste Tire Facility CI Compost Facility CI Process/Recycle Facility CI CIA Landfill Site CI Refuse Vehicles (# of Units) Cl Dumpsters > 20 cu yd (# of Units) CI Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) CI Primary Care El Acute Care CI Skilled Nursing CI Large Generator 0 Small Generator 0 Limited Hauler El Transfer Station CI Veterinary Clinic 0 Common Storage Facility 0 2 - 10 O 11 - 60 CI > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Fonn EMERGENCY NOT FICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON SiltrAnms v A 49 S Day Ph 5 ht Ph 2-0°1 S--io 5 2-S2_. PAYMENT RECEivEr) JUN 27 2,, '17#1()A3u u19 evviRoN IN couN HEALTH D mENTAL ry EPAR NENT Kez-A- PROGRAM ELEMENT FEE INSPECTOR # 'D2. PERMIT VALID Check # ) AMOUNT PAID Cash REVIEWED BY OV\____ 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13