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SAN JOAQUIN COUNTY ENVIRONMENTQLrWEALTH DEPARTMENT. MASTERFILE RECORD INFORMATION FORM- PAYMENT ❑ New EH Pro ram at Existing Facility ❑New EH Program and New FacilityCEI VE6 Fa ifity ID �� Program Record ID OCT Q / , 222 W River Road Suite F Ripon, CA 95366 6 20M CI t FE ffi SAN JOAQUIry C (Please check the PROGRAM(1600)appropriate description and specify size,numbe11 1r of units and pertinent information.)I{EA�TN D BAR LIN FOOD ❑ Restaurant: Seating Capacity_ Square Footage Food Handlers Course required: YES ❑ No LJ ❑ ommissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines�Yber of Units Retad a ke quare footage .2,592 ❑ w/Meat Market only ❑ Multiple Departments IN Prepackaged Goods Only j .'n Mobile Food Vehicle—Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant❑ Produce Stand I ❑ Special Event—Dates of operation from to ❑ CFO ❑A ❑ S DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit_ ' CUPA ❑ Hazardous Materials Business Plan(1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200) > Tons Generated Per Year ❑ Tiered Permitting Facility—> ❑ CA(2232) ❑ CE(2233,2234,2235,2237) ❑ PBR(2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST)(2800) Number of ASTs ❑ Underground Storage Tank Program(UST)(2300) Use UST A and B forms ❑Other CUPA Program HOUSING PROGRAM(2400) ❑ HotellMotel--Number of Units ❑Jail or Exempt Institution—Number of Units Employee Housing(2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility_ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm-------Maximum number of birds ❑ Kennel TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) . ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art Facility-Single Use(4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper VehicleRegislration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of Units) ❑ Dumpsters>20 cu yd(#of units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 1:12-10 011 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600)Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTA_CTP-ERSON Uttamlin Sing I �7 DayPh• 209241022 igh(:ph 2092410228 PROGRAM ELEMENT & F (• ❑ Surchar e F E ❑ Other FEE INSPECTOR# a PERMIT ALID �� 6 Z0 IO X63 El Food Handler ❑ Check AMOUNT PAID • VIJ Date 1 1! 2.0 INVOICE# 3 /-2- 11 Cash REVIEWED BY ACCOUNTING OFFICE 'AaDate 48-02.034MASTERFILE RECORD INFORMATION PINK 7/23/13 n��115-14 /l..l O O