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R 'flge c,, _N7- / v <br />2 7 <br /> <br />Facilit4 ID r/4 00 2-7736, Program Record ID PRD5-1-1-$6.36) s4 N Jo 2023 <br />_&,\1 [4,Quilv <br />-Facility Addres& 9 58 elood tAM rl Pr k i pori) c3t4 q5-34'la--1V/11 4?-7-, . .... ..— _.... — _, •__TDA , 4 , <br />(Please check the appropriate description and specify size number of units and pertinent information.) _ • <br />To06 PRoGi2A-00,), <br />4:1 Rest Square Footage Food Handlers Course required: YES 0 Nolg. ' urant: Seating Capacity <br /> <br />XrComn issary 0 Dry storage only 0 with Food Preparation )Vending Machines Number of Units <br />Retail Market---Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br /> <br />0 Mob;le Food Vehicle --Make Vehicle Type Color <br />, Registration # License # Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br /> <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 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 />0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Unddrground 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 MMGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Envi;onmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPUSEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPUSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREAT) ONAL HEALTH PROGRAM (3600) <br />Number iof Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Po ol/Spa 0 Natural Bathing Area <br />VECTOR <br />Poul <br />TATTOO <br /> <br />CONTROL PROGRAM (4000) <br />ry Farm ----Maximum number of birds <br />BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />0 Kennel <br /> <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body <br />Body Art Facility-SterIllzation (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # Capacity <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 AgICannery Waste Site <br />0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refule Vehicles (tt or Units) 0 Dumpsters > 20 Cu yd (tt of Units) <br />MEDICA <br />t <br />WASTE PROGRAM (4500) <br />Prim ry Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Tran fer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 -60 0 > 60 generators <br />PUBLIC ATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />'CoisITACtkikgdri n <br />glutERG7_ENCY NOTIFICATION FOR THIS FACILITY AND/OR 1:FLOGRAM ., (e6ci (D147_7000 <br />-Day Ph 6 Night-Ph <br />PROGRAM ELEMENT g1 FEE d 2. 0 Other FEE <br />PERMIT VALID <br />Date <br />ACCOUNTING OFFICE <br />SA N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New .EH Program at Existing Facility KNew EH Program and New Facility <br />Art Facility-Single Use (4120) <br />Art-Temp Event Mobile Facility (4131) <br />Vehicle # <br />----Number of Units <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />INSPECTOR # <br />Check # CeeLfV AMOUNT PAID <br />Cash REVIEWED BY r_ <br />48-02-034 <br />1/23/13 <br />0 Surcharg9 FEE <br />to 6/30 z <br />MASTERFILE RECORD INFORMATION PINK <br />0 Food Handler <br />INvOICE # 3 S 513 <br />Date