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ew EH Program at Existing Facility d ZNew EH Pro ramand New Fycilit <br />Facility ID F71?"77 2/11" Program Record ID <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION,RM <br />0 Other FEE <br />1:1 Food HancAfr <br />NVOICE # <br />0 Surcha <br />to <br />Date <br />REVIEWED BY ACCOUNTING OFFICE ate 2 <br />48-02-034 A TERFIL CORD INFORMATION PINK <br />PROGRAM ELEMENT (c3OS FEE <br />INSPECTOR # '% 2_5- PERMIT VALID <br />Check # C 6--- AMOUNT PAID <br />Cash <br />Facility Address- e`001)0,,,,ss Stm 41-HA- <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 />Retail Market----Square footage 0 w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # 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 P-tF0 -ErA 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 />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 />0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned NW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 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) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) <br />LIQUID WASTE PROGRAM (4200) <br /> License # Capacity Vehicle # 1:1 Pumper VehicleRegistration # <br /> <br />0 Package Treatment Plant 0 Chemical Toilets ----Number of Units Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />0 Transfer Station <br />0 Compost Facility <br />Food Handlers Course required: YES El No 0 <br />:Wending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />0 Spa <br />0 Water QualipAwglariSite <br />0 Out of Service Pool/Spa 0 fiteCOVettre a <br />'Qhn t/69 2023 SAN <br />JOAQU/N CO/lit <br />0 Body Art Fad% QN440,1*TY <br />0 Body Art-Temp Event oilkArhfintty (4131) <br />Li <br />Landfill <br />Waste Tire Facility <br />Refuse Vehicles (4 of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (4 or units) <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSOR, EV 1 1.47TMVV1A, 0 c 2 Day Ph( 1.-41,01. L780 - 3 'tight Ph <br />1/23/13