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Treatment Plant El Chemical Toilets ----Number of Units <br />El Ag/Cannery Waste Site <br />0 Process/Recycle Facility <br />El Dumpsters > 20 cu yd (# of Units) <br />El Sludge/Ash Site <br />El CIA Landfill Site <br />0 Farm/Ranch Cleanup Site <br /> <br /> <br /> <br />SAN JOAQUIN COUNTY E RONMENTAL HEALTH DEPART ff <br />MASTERFILE RECORD INFORMATION FORM <br /> <br /> <br />New EH Program at Existing Facility ONew EH Program and New Facility <br /> <br />Facility ID OLD)41 -- <br /> <br />Program Record ID kos-L1-,2S-37-- <br /> <br />PAYMENT <br />RECEIVED <br />t-E8 02 2018 <br />Facility Address 17/7 S 0,-7;0.in J)--, 1-°6-"kiv"" C° 95. HEALTH ARIY <br /> <br />DEPARTMENT <br /> T <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />El Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs0:1 No 0 <br />Commissary El Dry storage only 0 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 C.--, A.4c, Vehicle Type Color <br />Registration # License # 9 9 --,,I.cm ,,.. Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />El Temporary Food Facility --Dates of operation from to 0 Ice Plant 1:1 Produce Stand <br />Special Event---Dates of operation from to El CFO 0 A ID B <br />DAIRY PROGRAM (2000) <br />El Grade A Dairy <br />CUPA <br />0 Grade B Dairy El Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program El Program 1 Facility El Program 2 Facility El Program 3 Facility <br />Hazardous Waste Generator (2200) > Tons Generated Per Year <br />0 Tiered Permitting Facility > 0 CA (2232) El CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />l Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />l Other CUPA Program <br />HOUSING PROGRAM (2400) <br />El 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 />El Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site El NPL/SEP Cleanup Site 0 UIC Site <br />CI Abandoned HW Site El non-NPLJSEP 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 <br /> <br />0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />El Body Art Practitioner Reg (4110) El Mechanical DSPS Notification (4115) El Body Art Facility-Single Use (4120) <br />El Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) El Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # <br />El Pumper Yard 0 Package <br />SOLID WASTE PROGRAM (4400) <br />El Landfill <br /> <br />I=1 Transfer Station <br />Waste Tire Facility El Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />El Primary Care 0 Acute Care <br />El Transfer Station El Veterinary Clinic <br />License # <br /> <br />Capacity Vehicle # <br /> <br />0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />0 Common Storage Facility 0 2 - 10 0 11 - 60 1:1 > 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`:„3 f Day Ph r7 241-1. 2_2r-'123Night Ph 2..(Lr-4- 2-z - Z_Ze <br />PROGRAM ELEMENT , I t.r-15 ----) FEE 2-----) 0 Surcharge FEE 0 Other FEE <br />INSPECTOR # '1766 i PERMIT VALID D..(S..., 1 `-t , to /?,/"! (1 Z 1=1 Food Handler <br />71-Check # 1(0 o'-k AMOUNT PAD -..-3 Date INvoicE # 3o 0(6 <br />Cash REVIEWED BY ACCOUNTING OFFICE Date <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />1/23/13