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'SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />PA Lqz- , irincAn- <br />New EH Program at Existing Facility Pl(ew EH Program and New Facility Rt CE/Vei; <br />°FEB 0 7 , <br />Facility Address I.A. 0 valA —*it\ S\-- Nia.,PAA-0 Clik ctkz---c-keo,,Nj... 424 <br />c •mQ (Please check the appropriate description and specify size, number of units and pertinent information.) /14-/LVTI/H/RokVeC4.,tejiNn, <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 PA R 74Tter <br />Commissary 0 Dry storage only CI with Food Preparation OVending 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 />VAobile 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 />Facility ID fAar32_7()s-,5 Program Record ID <br />DAIRY PROGRAM PROGRAM (2000) <br />El 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 />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 />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site CI 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 />CI Poultry Farm Maximum number of birds CI 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 />CI Waste Tire Facility CI Compost Facility I=1 Process/Recycle Facility CI 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 />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON.OkkVCVNA--- Day Ph 1...,..aLL-3 Night Ph 4;1X2L-afLYet i /7 — <br />PROGRAM ELEMENT kJ 0 -1-) FEE <br />INSPECTOR # PERMIT VALID -121E <br />Check # AMOUNT PAID 4= <br />El Cash REVIEWED BY OW, <br />17. 0-iX --1- I --le, I &365702 <br />00 CI Other FEE <br />ACCOUNTING OFFICE <br />Surchar e F E <br />to <br />00 Date <br />MASTERFILE RECORD I FORMATION PINK 48-02-034 <br />1/23/13 <br />ID Food Handler <br />INVOICE # 31) <br />Date