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Li Surch <br />to <br />Date <br />PROGRAM ELEMENT 16 g FEE <br />INSPECTOR # PERMIT VALID <br />Check # AMOUNT PAID <br />Cash REVIEWED BY <br />48-02-034 <br />1/23/13 <br /> 0 Other FEE <br />P-0 Y El Food Handler <br />INvoicE# 3)1—qa„ <br />/Date I 7 <br />MASTERFILE RECORD INFORMATION PiNK <br />rge <br />ACCOUNTING OFFICE <br />1//1/2'vY <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />ENew EH Program and New Facility <br />Facility ID 04---0-0 Program Record ID &DS-16 0 <br />Facility Address 704 N Jack Tone RD Ripon CA 95366 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Cl Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 <br />Commissary Cl Dry storage only Li with Food Preparation 0Vending Machines Number of Units <br />''Retail Market—Square footage 2000 Li w/Meat Market only 0 Multiple Departments CI Prepackaged Goods Only <br />Li Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />CI Mobile Food Prep Unit-- Make Vehicle Type Color <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 Li AD B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy CI Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />CI Hazardous Materials Business Plan (1900) Number of chemicals: <br />Li CalARP Program CI Program 1 Facility LI Program 2 Facility 0 Program 3 Facility <br />CI Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />CI Tiered Permitting Facility > D CA (2232) CI CE (2233, 2234, 2235, 2237) D PBR (2231) CI PBR HHW (2236) <br />CI 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 CI 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 />El Environmental Assessment 0 UST-CAP Site 1=1 Local HW Cleanup Site El NPL/SEP Cleanup Site El UIC Site <br />CI Abandoned HW Site Li non-NPUSEP Cleanup Site CI RWQCB Cleanup Site D Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility D Pool CI Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />El Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />El Body Art Practitioner Reg (4110) Li Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) El Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard D Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station Li Ag/Cannery Waste Site El Sludge/Ash Site <br />Waste Tire Facility CI Compost Facility Li Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (# of Units) Li Dumpsters > 20 cu yd (# of Units) 0 Farm/Ranch Cleanup Site <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 CI 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 Gulbahar Saini Day Ph 4242045421 Night Ph <br />CI New EH Program at Existing Facility