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Cash REVIEWED BY ACCOUNTING OFFICE <br />48-02-034 <br />1/23/13 oc_c <br />Piel ym , _ r <br />i ci6Ali) <br />,5- SA N j04 <br />22 <br />E"V/RON4zNT4L <br />Quitv couN Ty <br />Facility Address Q\ c't o 1 l' -T-rcA.c <br />E 1-Y -A LTH 0 E IDA Li, 77.14Nr. <br />(Please check the appropriate description and specify size, number of units and pertinent Information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 0 Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units 0 Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only 0 Mobile Food Vehicle --Make Vehicle Type Color Registration 44 License # Sticker # 0 Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # <br />0 Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand 0 Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />0 CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility 0 Hazardous Waste Generator (2200) > -Tons Generated Per Year 0 Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) 0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs 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 Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) 0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site 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 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 Kennel <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 />0 Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # Capacity Vehicle # 0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (# of Units) 0 Dumpsters > 20 cu yd (# of units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler 0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2-10 0 11 - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />4 LAKEE <br />yMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON JERROD <br />PROGRAM ELEMENT \ ‘10 ‘C) FEE 2S7 Surcharge FEE 0 Other FEE <br />INSPECTOR # L Nr\ho.res PERMIT VALID h2.- 2-1 - to 2. - S 0 Food Handler <br />0 Check # V / AMOUNT PAID -77%2 S7 oe) Date 2 2, INVOICE # <br />Date <br />MASTERFILE RECORD IN OR ATION PINK <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Pro ram at Existing Facilit <br /> fps 1-1-8'.2-- <br />FEB 2024 ONew EH Pro ram and New Facility <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />Day Ph 209-399-0888 Night Ph 925-967-3809