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r <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />New EH Program at Existing Facility ONew EH-P-ro ram and New <br />I Facility ID ri,-1715-D 1.01.) Pro ram Recor. Dr) <br />Facility Address 9 Vt. t t4 -e---(A 615-111 <br />) (Please check the appropriate description and specify size, number of units and pertinent Information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES, No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation :Wending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <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 0 A 0 B <br />MASTERFILE RECORD INFORMATION FORM <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <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 />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 />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPUSEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPUSEP 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 />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 # <br />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 0 Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (# of Units) 0 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 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 /> <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON a A e • IREIMIP11%•R • Day Ph --_714.--jj)31light Ph 4-68-784-0321 <br />PROGRAM ELEMENT FEE alb t) — <br />Check # '\115 Ft- <br />Cash REVIEWED BY <br />INFORMATION PINK TERFILE R COR PINK <br />0 Other FEE <br />to • • 1:1 Food Hat2t%- <br />AMOUNT PAID / 04c) - Date NVOICE # <br />INSPECTOR # <br />surCr EE <br />PERMIT VALID Cc, 2- .S• 2. L-1 <br />ACCOUNTING OFFICE Date <br />1/23/13 \,Q