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CINew EH Program and New Facility <br />Program Record ID PPOS+g7/4- <br />-), Facility Address hp&O/ A/aria, 1e1 Lc.rap,'?5336 <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 YES 0 <br />Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />D. Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Ni Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # y Ca 3 <br />Mobile Food Prep Unit-- Make Vehicle Type <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 />Facility ID <br />Clew EH Program at Existing Facility <br />required: Food Handlers Course r <br />Sticker # <br />Color <br />PROGRAM ELEMENT \\C-sS.2) FEE _ <br />INSPECTOR # . 2—._ L.. PERMIT VALID <br />1:1 Check # <br />Cash REVIEWED BY <br />to <br />Date <br />ACCOUNTING OFFICE <br />0 Other FEE <br />El Food Handler <br />INVOICE # <br />Date I <br />S <br />2ô 3 <br />AMOUNT PAID Gs <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />DAIRY PROGRAM (2000) <br />CI 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 />El Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) El 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 Housino/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment CI UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 1:1 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 CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />CI 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) 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 />Pumper Vehicle Registration # License # <br />Pumper Yard El Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station CI Ag/Cannery Waste Site <br />Waste Tire Facility CI Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (# of Units) 0 Dumpsters > 20 cu yd (4 of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 1:1 Acute Care 0 Skilled Nursing 0 Large Generator <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility CI 2 - 10 0 11 - 60 CI > 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 PERSON TaelCe.,-) ▪ Day Ph 5/0 &tie -'2(p /-Night Ph xelf <br />48-02-034 <br />1/23/13 IL61 IbMa <br />MASTERFILE R CORPINFORMATION PINK <br />0 Kennel <br />Capacity Vehicle # <br />Sludge/Ash Site <br />CI CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />0 Small Generator El Limited Hauler