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Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd of units) <br />Slud PAYMENT <br />CIA <br />ED Farm/Ranctdr arttipkite <br />0 <br />0 <br />0 <br />Other FEE <br />Food Hater <br />INVOICE # <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION <br />New EH Program at ExistingFacility New EH Program and ,New Facility <br />Facility ID =9:196Fibri) 211 Program Record ID PLO '6- la3 <br />Facility Address '90 6 /9-32-P JA4 <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 Food Handlers Course required: YES 0 No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />rMobile 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 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 CI 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 C1 UST-CAP Site CI Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site El 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 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 />License # <br />0 Package Treatment Plant <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />H ENVI THRONMENTAL <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM DEPAfRTMENT <br /> Day Ph Night Ph <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />CI Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care CI Acute Care 0 Skilled <br />0 Transfer Station CI Veterinary Clinic <br />Nursing 0 Large Generator 0 Small Generator <br />0 Common Storage Facility 0 2 - 10 0 11 <br />0 Limited <br />6 6AN „Ow tamoitjAW <br />0 5 we <br /> Capacity Vehicle # <br />CI Chemical Toilets ----Number of Units <br />CONTACT PERSON <br />0 Surcharge,FEE, <br />to 12--0112 <br />Date _4512-3 <br />CdCash12.-i. REVIEWED BY ACCOUNTING OFFICE e Date 4 / 2A72.:..3 <br />48-02-034 MASTERFILE R CORD INFORMATION PINK <br />1/23/13 <br />PROGRAM ELEART 4Cg.5 FEE ñ'7 2U <br />1.'‘f <br />INSPECTOR # 742, C,PERMIT VALID 015123 <br />Check # AMOUNT PAID