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PROGRAM ELEMENT i FEE <br />INSPECTOR # /0 Ezi PERMIT VALID <br />El <br />CI Check # <br />Cash <br />Amou T PAID <br />REVIEWED BY ACCOUNTING OFFICE <br />c <br />tii\ MASTERFILE RECORD INFORMATION FORM <br />SAN JOAQUIN COUNTY E RONMENTAL HEALTH DEPART NT <br />New EH Program at Existing Facility ONew EH Program and New Facility <br />Facility ID OD24-7X3 Program Record ID Pk/J:64363 <br />Facility Address //0 rciaz? / .Q0 9 S—V/ <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 <br />Commissary CI Dry storage only CI with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />qa Mobile Food Vehicle --Make Vehicle Type <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />CI Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />Cu PA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />El 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 > Cl CA (2232) 0 CE (2233, 2234, 2235, 2237) CI PBR (2231) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />CI 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 CI Local HW Cleanup Site CI NPL/SEP Cleanup Site CI UIC Site <br />Abandoned HW Site El non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site CI 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 CI Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />El Body Art Facility-Sterilization (4121) CI 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 />CI Landfill 0 Transfer Station El Ag/Cannery Waste Site 0 Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility CI Process/Recycle Facility 0 CIA Landfill Site <br />CI Refuse Vehicles (# of Units) El Dumpsters > 20 cu yd (# of Units) 0 Farm/Ranch Cleanup Site <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 CI Veterinary Clinic 0 Common Storage Facility CI 2 - 10 CI 11 - 60 CI > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application F01717 <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />License #-/P44 SL0 O 51 Sticker # <br />Vehicle Type Color <br />Food Handlers Course r <br />OVending Machines Nu <br />CI Multiple Departments 0 <br />Vp <br />mber of UnitY <br />Prereglgwat Good <br />Tqf — <br />/3 <br />/SP "VA <br />'11% (rki <br />equired: <br />olor P NMEAL <br />o <br />License # Sticker # <br />to 0 Ice Plant CI Produce Stand <br />0 CFO 0 A El B <br />MASTERFILE R CO INFORMATION PINK <br />Carl- <br />48-02-034 <br />1/23/13 LIP/ <br />CI Other FEE <br />CI Food Handler <br />INVOICE #7:// <br />Date