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Square Footage <br />0 with Food Preparation <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br /> <br />LI w/Meat Market only 0 Multiple Departments El Prepackaged Goods Only <br />Vehicle Type <br />License # 1 -11290 <br />Color IS /1/011/-6 <br />Sticker # L.( 7 2- <br />Vehicle Type Color <br />License # Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />to OCF0 0A0B <br /> Capacity Vehicle # <br />El Chemical Toilets ----Number of Units <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />El 11 -60 0 go 260 rators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form Jo A Qt.iliv r, E -G.CY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />Day PhVi:YRELD-71ight Ph rti <br />if <br />SAN JOAQUIN COUNTY E ONMENTAL HEALTH DEPAIT, <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility lirriNew EH Program and New Facility <br />Facility ID Program Record ID •i-?R.DS-1/177 -7 <br />Facility Address ,..5 -18.8 E•e_arpeoief Rd, 5/- 9 /7 <br />(Please check the appropriate description aWspecify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make MVI CO/ <br />OICF-1011F c Registration # 1-1 5 (i'Di) <br />Mobile Food Prep Unit-- Make <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CU PA <br />0 Grade B Dairy 1=1 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 0 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) 0 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 0 UIC Site <br />Abandoned HW Site LI 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 0 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 /> <br />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) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # <br />Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />0 Refuse Vehicles (# of Units) LI Dumpsters > 20 cu yd Of UMW <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator <br />0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 <br />CONTACT PERSON <br />PROGRAM ELEMENT FEE <br />INSPECTOR # PERMIT VALID Li t <br />0 Surcharge FEE <br />to 7-4 1 / 1 -7 <br />0 Other FEE <br />0 Food Handler <br />Check # AMOUNT PAID <br /> <br />Date <br /> <br />INVOICE # 2 0 Co <br /> <br />be) LI Cash REVIEWED BY itii IV1 ACCOUNTING OFFICE Date <br />41182-30/21-3034 \ MASTERFILE RECORD INFORMATION PINK