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Cash REVIE1NED BY <br />48-02-034 <br />1/23/13 TAAji p, 04 ftr <br />ACCOUNTING OFFIC <br />0 Other FEE <br />0 Food HandArr <br />INVOICE # 9-3g — <br />Date 2,,E,2,22 <br />MASTERFILE RECORD 1 FORMATION PINK <br />0 Surch <br />to <br />Date <br />PROGRAM ELEMENT (42 1-1/4 FEE 3C5 <br />P TOR # 4-'58 9 LPERMITVALID <br />Check # 6 2.--c7 AMOUNT PAID 3 s- — <br />,• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Pro ram at Existing Facs, ONew EH Prop-am and New Facility <br />Facility ID <br />e <br />R.Or gs2.51 <br />Facility Address At.e97 Hea,rd-mr, Hwy Pkwy a <br />Food Handlers Course required: YEs-Er No 0 <br />Registration # <br />Mobile Food Prep Unit— Make <br />Registration # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event—Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) > -Tons Generated Per Year <br />Tiered Permitting Facility --> 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 Other CUPA Program <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 Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned NW Site 0 non-NPLJSEP 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 />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 Vehicle Registration # License # Capacity PAW/mil/ride # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets --neoffwb <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />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 <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 1 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />. EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PR <br />CONTACT PERSON <br /> it <br />Program Record ID p <br />(Please check the appropriate description and specify gm, <br />FOOD PROGRAM (1600) <br />esta u rant: Seating Capacity Square Footage <br />Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />Mobile Food Vehicle --Make <br />number of units an pertinent information •) <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Vehicle Type Color <br />License # Sticker # <br />Vehicle Type Color <br />License # <br /> Site Ag/Cannery Waste Site JUN zrg We/Ash Si <br />Process/Recycle Facility 0 oTATandfill Site <br />BAN JoAQU 0 Dumpsters > 20 cu yd (# of Units) _EtA4RoNglErnionitanch Cleanup Site <br />HEALTH DEPARTTau <br />0 Small Generator u Limited Hauler <br />0 0 11 - 60 0 > 60 generators <br />Day Ph Pir <br />OGRAM <br />Night Ph c)-6e) UM /SW