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Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Li Dumpsters > 20 cu yd (# ounits) <br />• <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 (r/ or units) <br /> Capacity Vehicle # <br />CI Chemical Toilets ---Number of Units <br /> License # <br />0 Package Treatment Plant <br />MEDICAL WASTE PROGRAM (4500) <br />0 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 ii -60 0 >60 generators <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 L 4 A A Day Ph q I - 08-0- Night Ph <br />PROGRAM ELEMENT 1624 FEE 35 5 <br />6213 PERMIT VALID 212-0/2-5/ t <br />V Sf-A-- AMOUNT PAID ,3S5 OD Date <br />ACCOUNTING OFFICE <br />-4t 1 -7012(-L'S <br />o Surch7e FE <br />O INSPECTOR # <br />Check # <br />0 Cash REVIEWED BY <br />4; 2 0 Food Handler <br />0 Other FEE <br />48-02-034 <br />1/23/13 <br />ORMATION PINK <br />7 INVOICE # <br />Date <br />MASTERFILE RECORD IN <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at ExistingFacility 0New EH Protram and New Facilit <br />Facility ID 0,2,57 .Program Record ID -6eas-ti-7'ots-3 <br />Facility Address (s.c.3 11/4) • chkff. LoOi Cpq D-640 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />IV Restaurant: Seating Capacity 2'14 Square Footage , I 00 <br />Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market--Square footage <br />Mobile Food Vehicle --Make <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 />0 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 CI Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />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 0 Out of Service Pool/Spa 0 Natural Bathing Area <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) 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 Mobile Facility (4131) <br />Li w/Meat Market only <br /> Vehicle Type <br />Registration # License # Sticker # <br />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 0A0B <br />Food Handlers Course required: <br />[Wending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />YES 09 No 0 <br />0 Kennel