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New EH Program at Existing Facility <br />Facility ID rAa(-);17 7 6,6 <br />:New EH Program and New Facility <br />Program Record ID PRos-q-s-ss-L, <br />0 Other FEE <br />ID Food Handler <br />INvoicE#) ID <br />Date <br />PROGRAM ELEMENT <br />INSPECTOR # ;-1CIA <br />Check # AMOUNT PAID Date <br />ACCOUNTING OFFICE <br />MASTERFILE R COR INFORMATION PINK <br />e F <br />31 23 <br />LI Surchar <br />to 12 <br />FEE <br />. PERMIT VALID <br />72- <br />Casht REVIEWED BY <br />48-02-034 <br />1/23/13 <br />0 Spa El Out of Service Pool/Spa 0 Natural Bathing Area <br />0 Kennel <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility Address 111 S. S.)- • Qh)tk-ItY1 CA 6152-et, <br />Registration # License # 0 \./14 i_Li 00 Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to 0CF0 0A0B <br />0 Grade B Dairy <br />Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility <br />Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) <br />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 />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 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 El Pool <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <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 # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Transfer Station <br />Compost Facility <br />Refuse Vehicles (4 or 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- 10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY 10TIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />Commissary 0 Dry storage only 0 with Food Preparation <br />l s:(11 Retail Market----Square footage 0 w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />Food Handlers Course required: YES 0 No 0 <br />:Wending Machines Number of Units <br />El Multiple Departments 0 Prepackaged Goods Only <br />Color <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />Hazardous Materials Business Plan (1900) <br />0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />0 Program 3 Facility <br />El PBR (2231) 0 PBR HHW (2236) <br />Landfill <br />Waste Tire Facility <br /> License # <br />0 Package Treatment Plant <br />El Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (4 of units) <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />PAYMp„,,„ <br />SludgpA <br />ii <br />/ Alte dr-1,11 <br />CIA Larial9 .:111WED <br />FarmytytcW4eanup Site <br />U / 2023 <br />0 Small Genera 12130.0Hauler <br />0 11 - 6Ei <br />EFIP144140"*.sA - ,rmENT <br />CONTACT PERSON (41-ro Nt144( Day Ph Night Ph