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New EH Program at Existing Facility <br />Facility ID --"Aex:3,2:7 <br />Facility Address ( / 7 5 <br />(Please check the appropriate description and <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Ft Mobile Food Vehicle --Make <br />ONew EH Program and New Facility <br />Program Record ID <br />/ i f112 S--19 <br />specify size, number of units and pertinent information.) <br />License # <br />to <br /> <br />Registration # p <br />Mobile Food Prep Unit-- Make <br /> <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from to <br />Food Handlers Course required: YES 0 No 0 <br />0Vending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Sticker # <br /> Vehicle Type <br />Yi...-7E17-gL License # 1--/VK gD1? <br />111 tt-t Vehicle Type <br /> Square Footage <br />0 with Food Preparation <br /> 0 w/Meat Market only <br />Sticker # <br /> 0 Ice Plant 0 Produce Stand <br />0 CFO 0 A 0 B <br />Color <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (4 of Units) <br />0 A45tI AtliblaitOUNTY <br />CF I nitlffNTAL <br />0 Farm an&P16041F4Tsite <br />PROGRAM ELEMENT <br />INSPECTOR # L <br />Check # (,C, <br />S 5.- FEE Other FEE 0 Surcharge FEE <br />Food Handler PERMIT VALID <br />AMOUNT PAID <br />Cash REVIEWED BY <br />INVOICE # <br />Date le) A. _3 <br />107 <br />2-37 <br />b 2.) <br />ACCOUNTING OFFICE <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 />Environmental Assessment 0 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 0 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 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br /> <br />0 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 />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event IRAIYIVENT131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles lit of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />RECEIVED Capacity Vehicle <br />0 Package Treatment Plant 0 Chemical Toilets --Number of Unt4CT 0 6 2023 <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 PERSON L..\5 V\.. 3CL J cue Day Ph )-2t1 -11423ight Ph <br />48-02-034 <br />1/23/13 <br /> <br />MASTERFILE REC R. INFORMATION PINK <br />I7000 &13-7 K r rrq Con <br />