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<br /> <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR i MENT <br />MASTERFILE RECORD INFORMATION FORM <br /> <br /> <br />CI New EH Program at Existing Facility <br /> <br />1:INew EH Program and New Facility <br /> <br />— <br />Facility ID rib° z2_ /5-6 <br /> <br />Program Record ID 12.06-3677 8--() <br /> <br />Facility Address 701 Pr,-h-A c-) Occ\cs-4-c, <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />c s <br />PAYMENT <br />RECEIVED <br />JAN 1 3 2 015 <br />SAN JOAQU/N COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />Square Footage Food Handlers Course required: YES El No El <br />1E1 with Food Preparation EVending Machines Number of Units <br />1E1 w/Meat Market only CI Multiple Departments E Prepackaged Goods Only <br />Vehicle Type Color <br />License # Sticker # 22-7g- <br />QC) Vehitle Type (--7‘ Color <br />ense # V/13P -WR_7t icker # Registration # <br />CI Temporary Food Facility --Dates of operation from to El Ice Plant CI Produce Stand <br />El Special Event---Dates of operation from to C] CFO El A 1:1 B <br />DAIRY PROGRAM (2000) <br />1:1 Grade A Dairy I: Grade B Dairy" El Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />El Hazardous Materials Business Plan (1900) Number of chemicals: <br />CI CalARP Program I: Program 1 Facility El Program 2 Facility CI Program 3 Facility <br />CI Hazardous Waste Generator (2200) > Tons Generated Per Year <br />El Tiered Permitting Facility > El CA (2232) El CE (2233, 2234, 2235, 2237) CI PBR (2231) CI PBR HHW (2236) <br />CI Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />D Other CUPA Program <br />HOUSING PROGRAM (2400) <br />El Hotel/Motel Number of Units El 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 />CI Environmental Assessment El UST-CAP Site El Local HW Cleanup Site 1:1 NPL/SEP Cleanup Site El UIC Site <br />CI Abandoned HW Site El non-NPUSEP Cleanup Site El RWQCB Cleanup Site CI Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility El Pool El Spa El Out of Service Pool/Spa El Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />1:1 Poultry Farm Maximum number of birds CI Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) El Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) <br />CI Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) C] Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />El Pumper Vehicle Registration # <br /> License # Capacity Vehicle # <br />CI Pumper Yard E Package Treatment Plant <br /> <br />D Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />El Landfill El Transfer Station <br /> CI Ag/Cannery Waste Site <br />CI Waste Tire Facility I: Compost Facility <br /> CI Process/Recycle Facility <br />CI Refuse Vehicles (# of Units) <br /> El Dumpsters > 20 cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />El Primary Care El Acute Care CI Skilled <br />I: Transfer Station CI Veterinary Clinic <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity <br />El Commissary El Dry storage only <br />CI Retail Market----Square footage <br />El Mobile Food Vehicle --Make <br />Registration # <br />K-Mobile Food Prep Unit-- Make <br />El Sludge/Ash Site <br />El CIA Landfill Site <br />CI Farm/Ranch Cleanup Site <br />Nursing E Large Generator CI Small Generator CI Limited Hauler <br />CI Common Storage Facility ID 2-10 CI 11 -60 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON (9,04)8-n-61c6 ‘Clev\CI <br /> Day Ph og u Night Ph <br />FEE <br />PERMIT VALID <br />Am UNT PAID <br />PROGRAM ELEMENT <br />INSPECTOR # <br />REVIEWED BY <br />4B-02-034 <br />1PV1/11 <br />), /::1) Date 1/4 3, IS- <br />ACCOUNTING OFFICE 6.2?Z641 <br />C3 Other FEE <br />El Food Handler <br />INvoicE# 251538 <br />MASTERFIL E REC RD INFORMATION PINK <br />00 CI Surcharge F E <br />to 1-1'3 <br />I: Check # <br />Cash Date VS--