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(c./3 INSPECTOR # PERMIT VALID <br />AMOUNT PAID <br />PROGRAM ELEMENT U. <br />Date <br />REVIEWED BY 6,1) 03 2-/ ACCOUNTING OFFICE <br />0 Surcharg <br />to <br />LLQ.heck# <br />Cash <br />FE 0 Other FEE FEE /$-o <br />0 Food Handler <br />INVOICE # I Liq <br />Date 05-1/2 <br />0 Chemical Toilets <br /> <br />Number of Units <br /> <br />Ag / Cannery Waste Site <br />Process/Recycle Facility <br />0 Dumpsters > 20 cu yd ----Number of Units <br />0 Sludge/Ash Site <br />0 CIA Landfill Site <br />0 Farm/Ranch Cleanup Site <br />,SAN JOAQUIN COUNTAULVIRONMENT,AL HEALTH DIViMIN <br />MASTERFILE R .EMINFORMATION FORM (EH 0069) <br />N4New EH Program at Existing Facility <br />:New EH Pro ram and New Facility <br />Facility ID 0/9 / 5) 33 Program Record ID <br />Facility Address 2c1L-t4 g 4( 12 _A-) <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity <br /> <br />Square Footage <br />Commissary 0 Dry storage only <br />0 with Food Preparation <br />Retail Market ----Square footage <br /> <br />0 with Meat Market only <br />License # <br />)4Mobile Food Prep Unit--Make C Vehicle Type <br />Registration # 66Hto 32_ /Li 533o6, i7,3 License # <br />Temporary Food Facility Dates of operation from to <br />Special Event --Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser---Number of Containers in Multi-Head Unit <br /> PAYME NT <br />R ECEIVED <br />AN 14 2004 <br />SA <br />Mobile Food Vehicle Make <br />Registration # <br />Vehicle Type <br />Sticker # <br />.3 :LTD 70,4 L., <br />Color <br />1 Sticker # (i? 47E <br />N JOAQUIN COUNTY <br />Food ENTAINTY Food Handlers CourctEk RAK- No 0 Ap <br />OVending Machines --Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />0 Ice Plant <br />0 Produce Stand <br />Tons Generated Per Year 0 Recycle / Exempt System <br />Tiered Permitting Facility 0 Conditionally Authorized (CA) 0 Conditionally Exempt (CE) <br />0 Permit-By-Rule Fixed Unit 0 Permit-By-Rule Household Hazardous Waste <br />0 ABOVEGROUND STORAGE TANK FACILITY (AST) (2390)----Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br />0 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 11W Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP 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 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Tattooing (4121) 0 Body Piercing (4120) 0 Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle-Registration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant <br />0 Transfer Station <br />0 Compost Facility <br /> <br />0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS E110069 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON 4/„_ 4-E_ ' "LI £4c4 Day Ph 7'3 -/ 2-5 7 Night Ph /2 - ci? <br />CUPA 0 State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />0 Hazardous Waste Generator <br />SOLID WASTE PROGRAM (4400) <br />Landfill <br />Waste Tire Facility <br />Refuse Vehicles --Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care <br />EH 0069 Pink Fomi Rev. 02/25/03