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PAYMENT <br />RECEIVED <br />MAY 1 9 2023 <br />ENVIRONMENTAL <br />TMENT H j9kOt <br />0 New EH Program at Existing Facility CI New EH Pro ram and New Facility SAN JOAQUIN COUNTY <br />Facility ID FAc0 7_76,g( Program Record ID IZOS-4-145-ct HEA LT <br />Facility Address 20 88 Cr .54,4, e d 1 114-rirce, CA 95"33‘ — 571-4r6tx,1-3 6' <br />(Please check the appropriate description and specify size number of units and pertinent information.) <br />F091 D PROGRAM (1600) <br />IZI Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation 0Vending Machines Number of Units <br />67 Retail Market—Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />1 Mobile Food Vehicle —Make Vehicle Type Color <br />Registration # License # Sticker # <br />Mobile Food Prep Unit— Make % Vehicle Type <br />Registration # License # Sticker tt <br />0 Temporary Food Facility —Dates of operation from to 0 Ice Plant 0 Produce Stand <br />0 Special Event—Dates of operation from to ICFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />0 CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200)----> Tons Generated Per Year <br />0 Tiered Permitting Facility —> 0 CA (2232) 0 CE (2233. 2234, 2235, 2237) 0 PBR (2231) CI PBR HHW (2236) <br />0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 Other CUPA Program <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 Houswq/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 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 />0 Poultry Farm --Maximum number of birds 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 # 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 0 Ag/Cannery Waste Site 0 Sludge/Ash Site <br />0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />0 Refuse Vehicles (4 of U > 20 cu yd (0 of liras) rits) 0 Dumpsters 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />0 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />0 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 END 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Of/ c('-ei (1 TT, —Li.eif Day Ph 20 ? 5'3 4 '{-..07:71ight Ph SWAIC <br />PROGRAM ELEMENT 1624 FEE 0 Surcharge FEE 0 Other FEE <br />INSPECTOR # 8788 PERMIT VALID 57M/23 to 302- 0 Food Handler <br />0 Check # 0.)eedif. AMOUNT PAID-t Date 5// INVOICE # <br />0 Cash <br />3F/ G <br />REVIEWED BY <br />Date S- <br />48-02-034 <br />ACCOUNTING OFFICE <br />MASTERFILE RECORD <br />113113 <br />_E5yt.1 # /62_q-b37s-21- <br />Scanned with CamScanner <br />NFORMATION PINK <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM