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.New EH Proram at Existing Facility g.........A <br />I Facility ID 1-- co Pro <br />.4 A <br />A 4 Facility Address <br />(Please check the appropriate description <br />FOO ROGRAM (1600) <br />estaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />0 Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />1r <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />and specify J, number of units and pertine <br />Square Footage /000 <br />0 with Food Preparation <br />0 w/Meat Market only <br />1/New EH Pro ram and New Facility <br />am Record I P <br />Vehicle Type Color <br />License # Sticker # <br />Vehicle Type Color <br />License # Sticker # <br />to 1:1 Ice Plant 0 Produce Stand <br />to 0 CFO DADB <br />Food Handlers Course required: YES VINO 0 <br />0Vending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br /> g1/4,11 <br />, <br />information.) <br />MA <br />— 0 Surch <br />to ) D <br />Date <br />ACCOUNTING OFFICE 4 ate <br />TERFILE RECORD IN ORMATION NK <br />Other FEE <br />Food Handler <br />INvOicE # 0 <br />PROGRAM ELEMENT <br />INSPECTOR # <br />0 Check # <br />0 Cash <br />48-02-03411 <br />1/23/13 <br />FEE <br />PERMIT VALID <br />AMOUNT PAID <br />REVIEWED BY <br />k_RIME4T- <br />Art Facility-Sing1W-Usi(61a23 <br />Art-Temp Evgai rylgobile Facility (4131) <br />4uAQUIN COUNTY ENVIRONMENTAL <br />- --Number --Number of Units <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />DAIRY PROGRAM (2000) <br />0 Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />U Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />U Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />U Tiered Permitting Facility ------> 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />0 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 NPLJSEP Cleanup Site 0 UIC Site <br />0 Abandoned HW Site 0 non-NPLJSEP 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 <br />VECTOR CONTROL PROGRAM (4000) <br />0 Poultry Farm—Maximum number of birds <br />TATrOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />0 Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) <br />0 Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) <br />).*QUID WASTE PROGRAM (4200) <br />0 Pumper Vehicle Registration # License # <br />0 Pumper Yard 0 Package Treatment Plant <br />SOUD WASTE PROGRAM (4400) <br />13 Landfill 0 Transfer Station <br />0 Waste Tire Facility 0 Compost Facility <br />0 Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />o Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator <br />0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 100 Small Generator 0 Limited Hauler <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use pws EHD 46-02-003 Blue Application Form <br />0 11 - 60 <br />EMERGENCY • ICATION F • RT s FACILITY AND/OR P OGRAM <br />ay Ph <br />0 Out of Service Pool/Spa 0 Natural Bathing Area <br />PAYMENT <br />REVEIVED <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (# otunits) <br /> Capacity <br />0 Chemical Toilets <br />Body <br />Body <br />0 > 60 generators <br />A CONTACT PERSON yr? 3 <br />Night Ph gy2i