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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />CI Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit <br />6 <br />CONTACT PERSON <br />Check # <br />CI Cash <br />CI Other FEE <br />48-02-034 <br />ONew EH Program and New Facility <br />Program Record ID it-4) 5 6 'ilbC) <br />Facility Address 505 Doak Blvd STE G, Ripon, CA, 95366 <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 />CI Commissary 0 Dry storage only 0 with Food Preparation CIVending Machines Number of Units <br />Retail Market----Square footage CI w/Meat Market only CI Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />i 0 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 />, CI Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />CI Hazardous Materials Business Plan (1900) Number of chemicals: <br />CI CalARP Program CI Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />CI Tiered Permitting Facility > 0 CA (2232) CI CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 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 />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />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 />Environmental Assessment El UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />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 CI Spa CI Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm------Maximum number of birds CI 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 />CI Body Art Facility-Sterilization (4121) CI 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 # Capacity Vehicle # <br />CI Pumper Yard 0 Package Treatment Plant CI Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill El Transfer Station El Ag/Cannery Waste Site 0 Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility CI CIA Landfill Site <br />Refuse Vehicles (it or units) El Dumpsters > 20 cu yd (if of Units) CI Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care Cl Acute Care 0 Skilled Nursing 0 Large Generator CI Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic CI Common Storage Facility 0 2 - 10 CI 11 -60 0 > 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 />PROGRAM ELEMENT 1921 FEE 0 Surcharge FEE <br />INSPECTOR # N. Loehrer PERMIT VALID to 0 Food Handler <br /> AMOUNT PAID Date INVOICE # ‘g 3 <br />REVIEWED BY ACCOUNTING OFFICE 4,77 Date .9 '2AD <br />MASTERFILE RECORD INFORMATION PINK