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0 0 Cash REVIEWED BY ACCOUNTING OFFICE <br /> 0 Other FEE <br />0 Food Handler <br />11--0 <br />NvoicE# 3, fcg <br />Date /J <br />AMOUNT PAID Date <br />PROGRAM EL_B_Mg <br />INSPECTOR # <br />CI Check # <br />T V2;7 -.7 FEE 0 Surcharge FEE <br />PERMIT VALID to <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility :New EH Program and New Facility <br />Facility ID FA0026394 <br />Program Record ID <br />Facility Address 12253 N CLEMENTS RD. LINDEN <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />CI Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 <br />CI Commissary CI Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />CI Retail Market----Square footage LI w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />CI Mobile Food Vehicle --Make Vehicle Type Color <br />Sticker # <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />0 Grade B Dairy CI 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 />[E] Hazardous Waste Generator (2200) >-Tons Generated Per Year 2220 (less than 5 tons) <br />CI Tiered Permitting Facility > CI CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) CI PBR HHW (2236) <br />CI Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />CI Other CUPA Program <br />HOUSING PROGRAM (2400) <br />CI Hotel/Motel Number of Units CI 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 />CI Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPLJSEP Cleanup Site 0 UIC Site <br />CI Abandoned HW Site El non-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site CI Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility CI Pool 0 Spa <br /> <br />0 Out of Service Pool/Spa <br /> CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />CI Poultry Farm Maximum number of birds <br /> <br />0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) CI 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 />CI Pumper VehicleRegistration # License # <br />CI Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill 0 Transfer Station El Ag/Cannery Waste Site <br />CI Waste Tire Facility 0 Compost Facility CI Process/Recycle Facility <br />Refuse Vehicles (# of Units) 0 Dumpsters > 20 Cu yd (r/ of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care 0 Acute Care CI Skilled Nursing CI Large Generator 0 Small Generator CI Limited Hauler <br />Transfer Station CI Veterinary Clinic 0 Common Storage Facility CI 2 - 10 0 ii - 60 CI > 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 /> Day Ph Night Ph <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />Registration # License # <br />CI Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to CI Ice Plant 0 Produce Stand <br />CI Special Event---Dates of operation from to CI CFO CI A 0 B <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />Sludge/Ash Site <br />CIA Landfill Site <br />0 Farm/Ranch Cleanup Site <br />CONTACT PERSON <br />1/23/13