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PROGRAM ELEMENT <br />_ <br />k \CO -1/41.3 FEE 0 Surcharge FEE 0 Other FEE <br />to 11 - 29 0 Food Handler <br />Date _a/ sp240 INvoicot b-t) g"--S <br />Date 1/1/2, ,-) <br />M <br />„0 <br />Aiii-g121,11F Ccirrn INFORMATIDN,FNK <br />( <br />INSPECTOR it • PERMIT VALID — <br />Check It V CC-7 AMOUNT PAID <br />o Cash <br /> RCVIlVI!s IW <br />48.02-031 <br />U23/13 <br />ACCOUN MSG OFFICE <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD _ <br /> <br />INFORMATION FORM I <br />s _ New EH Program at Existing Facility m <br /> . . <br />NI2tIew EH Pro rant and New Facility , - <br />1 Facility ID fittilD ,---.41 3 0 Program Record ID F sviiate <br />Facility Address '4-a c obi 1Pri-D i ANC- ., MOU NTA IN friov cA, 9-;- .31 I <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity Seuaie Footage Food Handlers Course required: YES No 0 <br />Commissary rit•Dry storage only lg with Food Preparation OVending Machines Number of Units <br />Retail Market----Square footage _ 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration li License II Sticker II <br />Registration if License ft Sticker II <br />0 Mobile Food Prep Unit-- Make Vehicle Type Color <br /> <br />to 0 Ice Plant 0 Produce Stand <br />to E co OAOB <br />DAIRY PROGRAM (2000) <br />Grade A Dairy U Grade B Dairy <br />CUPA <br />0 Hazardous Materials Business Plan (1000) 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 (72:16) <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 U Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housino/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJFCTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />0 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 <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 />Pumper VehicleRegistration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />0 Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (it ni units) <br />MEDICAL WASTE PROGRAM (4500) <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 <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 />CONTACT PERSON KA-v IcH D Day Ph 510 2- 3 7335 Night Ph . <br />C <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />0 Milk Dispenser -Number of Containers in Multi-Head Unit <br />0 Spa 0 Out of Service Pool/Spa 0 Natural ettylp <br />PA <br />RRECEIV ED <br />oa 2021 0 Body Art Facility-Single ta44 <br />License II <br />0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />Capacity <br />Ag/Cannery Waste Site 0 Sludge/Ash Site <br />Process/Recycle Facility 0 CIA Landfill Site <br />Dumpsters > 20 cu yd Of Unitt•) 0 Farm/Ranch Cleanup Site <br />0 11 - 60 0 > 60 generators <br />0 Body Art-Temp Event Mobile Fact(46-.63110 <br />spoi Aan'aNTAL- <br />'