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FR09441,052 <br />gCheck # AMOUNT PAID' <br />Cash REVIEWED BY <br />48-02-034 <br />1/23/13 <br />0 Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # 0 Temporary Food Facility -Dates of operation from <br />0 Special Event—Dates of operation from <br />DAIRY PROGRAM (2000) <br />0 Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit C_VP.J8 <br />0 Hazardous Materials Business Plan (1900) Number of chemicals: 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 <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms 0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />0 Hotel/Motel —Number of Units 0 Jail or Exempt Institution —Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) 0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPUSEP Cleanup Site 0 UIC Site 0 Abandoned HW Site <br />0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL. HEALTH PROGRANI (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) <br />0 Poultry Farm—Maximum number of birds <br />0 Kennel TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />0 Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) 0 Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) <br />0 Pumper Vehicle Registration # License # Capacity Vehicle # 0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets —Number of Units SOLID WASTE PROGRAM (4400) <br />0 Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site 0 Waste Tire Facility 0 Compost Facility <br />(Is of UnitS) <br />0 Process/Recycle Facility 0 CIA Landfill Site <br />MEDICAL WASTE PROGRAM (4500) <br />0 Refuse Vehicles <br />0 Dumpsters > 20 Cu yd (# of Units) 0 Farm/Ranch Cleanup Site <br />0 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 PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS El-ID 46-024)03 Blue App//cat/on Form <br />CONTACT PERSON <br /> <br />MEROEN Y No ATION FOR THIS FACILITY AND/OR PROGRAM ( \-)\ <br />Day Ph (-:•; Night Ph PROGRAM ELEMENTkk. 17) FEE 2 0 Surcharge Fee 0 Other FEE INSPECTOR # — PERMIT VALID - to \--4 <br />0 Food Handler <br />Date INVOICE # <br />Date <br />I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT I <br />MASTERFILE RECORD INFORMATION FORM <br />1 <br /> 0 New EH Pro ram at Existing Facill l'New EH Program and New Facility PCI"/ P7. Facility ID -F-- a/D231 4-( Pro ram Record ID 0)5-, IP D32_ 4PR 00 <br /> <br />Facility Address -3c), \OEsT 11 41 MIL=°- -111""/ c-A cilD--14 sx'Atio4 „„ 4 2°24 <br />EL:X2pfagaum (1600) <br />(Please check the appropnate description and specify Size, number of units and pertinent Intormation 0.2/471.CouA, <br />Air 'vrV u P,,i • 44. 0 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 12i4b70 <br />0 Commissary 0 Dry storage only 0 with Food Preparation I:Vending Machines Number of Units pf Retail Market—Square footage 0 w/Meat Market only 0 Multiple Departments 2-Prepackaged Goods Only 0 Mobile Food Vehicle -Make <br />Sticker # <br />ACCOUNTING OFFICE <br /> Color <br />Sticker # <br /> to 0 Ice Plant 0 Produce Stand <br />Registration # Color Vehicle Type <br />License # <br />to 0 CFO 0 A ID 8 <br />.• <br />Mgr <br />MASTERFILE R ORD FOR TION PINK