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PROGRAM ELEMENT FEE\C6 kTh — <br />INSPECTOR # _...\(-\\C\CA( e3ERMIT VALID - 2_q <br />CI Check # Cee..ch- AMOUNT PAID 106.ao <br />El Cash REVIEWED BY <br />48.02-034 <br />1/23/13 <br />0 Surcharge FEE 0 Other FEE <br />to 7' 0 Food Handler <br />Date - INVOICE # <br />ACCOUNTING OFFICE 7 7 Date <br />MASTERFILE RECORD NFORMATION PINK <br />SAN JOAQUIN COUNTY ENVIRONMENTAL IlEA1 'Ill DEPARTMENT <br />MASTERFILE RI -CORD INITORMAIION I ()UM <br />0 New EH Program at Existin9 Faculty Program and Now Facility <br /> <br />Facility ID F-A,:e,0 5-0 i'll)91:1111 Record ID U5'-/-g 2J <br />Facility Address i2c Ls. 1 vc 11•I 0i0c, m 1-tpt)(,, ,L$1 1S'31 <br />(Please check the appropriate description and spe.fj of .1./r!ts and p_ertinent information <br />FOOD PROGRAM (1600) <br />CI Restaurant Seating Capacity <br />via-Commissary Crbry storage only <br />Retail Market----Square footage <br />CI Mobile Food Vehicle --Make <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />Vehicle Type Color <br />License # Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />to 0 CFO 0 A 0 B <br />Pie147 <br />1vT" <br />FE8 0 <br />SIAN JOAQU/N <br />1 2024 <br /> COUNTY HEA L <br />7-H DEP,4 <br />Food Handlers Course required: YES 0 No 0 <br />t):21.1,1th Food Ire OVending Machines Number of Units <br />vdivi:7F,t'.7,imicet only CI Multiple Departments 0 Prepackaged Goods Only <br />',.'ehcle Type Color <br />License # Sticker # <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy <br />CUPA <br /> <br />0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals. <br />El CalARP Program CI Program 1 Facility El Program 2 Facility <br /> <br />0 Program 3 Facility <br /> <br />Hazardous Waste Generator (2200) > -Tons Generated Per Year <br />Tiered Permitting Facility > CI CA (2232) El CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 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 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 />1:1 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPLJSEP Cleanup Site 0 UIC Site <br />Abandoned HW Site Cl 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 CI Pool CI Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />CI Poultry Farm Maximum number of birds <br /> <br />CI Kennel <br />TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) O Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) Cl Body Art Temp Event Co-ord (4130) O Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant <br /> <br />0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br /> CI Ag/Cannery Waste Site <br />Waste Tire Facility CI Compost Facility <br /> 0 Process/Recycle Facility <br />Cl Refuse Vehicles (# of units) <br /> El Dumpsters > 20 cu yd of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic CI Common Storage Facility 0 2 - 10 <br /> <br />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 5HR1sJTA-Naz ki TA-N c Day Ph 2 CIC,CIS 13G 3 Night Ph 20165-t1V.3 <br />0 Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site