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PROGRAM ELEMENT 22 -4:7 FEE 12 Surcharge FEE 0 Other FEE <br />INSPECTOR # C46 9/Z7/ePERMIT VALID to 0 Food Handier <br />Check # AMOUNT PAID Date Jfl INVOICE # <br />0 Cash REVIEWED BY ACCOUNTING OFFICE Date ¶73 <br />0 AgICannery Waste Site <br />ProcesslRecycle Facility <br />Dumpsters > 20 Cu yd (it of units) <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />SAN JOAQUIN COUNTY LARONMENTAL HEALTH DEPAR - '7 NT <br />MASTERFILMECORD INFORMATION FORM <br />0 New EH Program at Existing Facility I:New EH Program and New Facility <br />LFacIlity ID 5 4 181 Program Record p ek,25,3„fit/ <br />Facility Address g _co 0.. --3--Jimp/(7 fcLl - <br />(Please check the appropriate description <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity <br />0 Commissary 0 Dry storage only <br />Retail Market--Square footage <br />Mobile Food Vehicle —Make <br /> <br />Registration # <br />0 Mobile Food Prep Unit Make <br /> <br />Registration # <br />Temporary Food Facility —Dates of operation from <br />0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />0 Recycle/Exempt System (2299) <br />0 Appliance Recyclers (2217) <br />Tiered Permitting Facility----------- 0 Conditionally Authorized (CA) 0 Conditionally Exempt (CE) <br />)(ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />0 Permit-By-Rule Fixed Unit 0 Permit-By-Rule Household Hazardous Waste <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <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 Came Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPUSEP Cleanup Site 0 UIC Site <br />0 Abandoned HW Site 0 non-NPUSEP 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 />TATTOO. BODY PIERCING. PERMANENT COSMETIC PROGRAM (4100) <br />0 Tattooing (4121) 0 Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets --Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />0 Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />0 11 - 60 0 > 60 generators Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02403 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />48-02-034 <br /> MASTERFILE RECORD INFORMATION PINK <br />11115J07 <br />and specify size, number of units and pertinent information.) <br />Special Event Dates of operation from to <br />DAIRY PROGRAM (2090) <br />Grade A Dairy 0 Grade B Dairy <br />CUPA El State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />Hazardous Waste Generator Tons Generated Per Year <br />CRT Offsite Handlers (2218) ------- 0 Silver Only (2222) <br />Square Footage <br />0 with Food Preparation <br />0 with Meat Market only <br />Food Handlers Course required: YES 0 No 0 <br />I:Vending Machines Number of Units <br />0 Multiple Departments0 Prepackaged Goods Only <br /> Color <br /> Sticker # <br /> Vehicle Type Color <br />License # Sticker # <br />to 0 Ice Plant <br />Vehicle Type <br />License # <br />0 Produce Stand <br />0 Kennel <br />0 Permanent Cosmetics (4122)