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New EH Program at Existing Facility ONew EH Program and New Facility <br />Facility ID F-Aoo Program Record ID ,-P-DSLI-g3 1-1--g <br />Facility Address iatt S. 7.44.‘ s-t. Mode.S-to CA 615351 <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 />III‘Aobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # E q DAD 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 />Food Handlers Course required: YES 0 No 0 <br />:Wending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />SAN JOAQUIN COUNTY H__ENVIRONMENTAL <br />EALTH DEPARTMENT <br />DRP EEA CC1 f2EM 6IEV 2 OEN 2 3DT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />PROGRAM ELEMENT 110 35 FEE <br />INSPECTOR # G-F PERMIT VALID <br />AMOUNT PAID <br />REVIEWED BY <br />Surcharg FEE <br />to I 31 <br />Date <br />ACCOUNTING OFFICE <br />Other FEE <br />Food Handler <br />INVOICE # 3'708-.3-0 <br />Date 2-62-5 <br />„jgCheck # <br />Cash <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters >20 cu yd (# of Units) <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CU PA <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 />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 <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 />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Sma <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2- 10 <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 Bt-k- A Day Ph (;c1 ,4 Night Ph <br />0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />0 Kennel <br />Body Art Facility-Single Use (4120) <br />Body Art-Temp Event Mobile Facility (4131) <br />License # <br />0 Package Treatment Plant <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />ll Generator 0 Limited Hauler <br />11 - 60 0 > 60 generators <br />, A . A 11) <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />1/23/13