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SAN JOAQUIN COUNTY E RONMENTAL HEALTH DEPART_ 1+1T MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility :New EH Program and New Facility PAYMENT RECEIVED APR 1 2 2018 Facility Address 17 17 c_S , U 41 e:Tn 5-ert.4-O--r\ Ce„ C71/1 SAN JOAQUIN COUNTY ) (Please check the appropriate description and specify size, number of units and pertinent information.) ENVIRONMENTAL FOOD PROGRAM (1600) HEALTH DEPARTMENT Restaurant,: Seating Capacity Square Footage Food Handlers Course required: YES EI No 0 Commissary 0 Dry storage only 0 with Food Preparation 0Vending Machines Number of Units Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only Mobile Food Vehicle --Make Vehicle Type Color Registration # License # Sticker # NZI Mobile Food Prep Unit-- Make H 1515A e pa d Q, Vehicle Type '-"A • , 111, _ a' oT Color i p"p Registration # License # 4/RC /4 i ( Sticker # Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand Special Event---Dates of operation from to Facility ID 0-0C)I LoLo Program Record ID 5-4z_q2z-- 0 CFO 0 A 0 B DAIRY PROGRAM (2000) Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit CU PA Hazardous Materials Business Plan (1900) Number of chemicals: CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility Hazardous Waste Generator (2200) > Tons Generated Per Year Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) Aboveground Storage Tank Facility (AST) (2800) Number of ASTs Underground Storage Tank Program (UST) (2300) Use UST A and B forms Other CUPA Program HOUSING PROGRAM (2400) 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) Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site Abandoned HW Site 0 non-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) Poultry Farm Maximum number of birds 0 Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) 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) Pumper Vehicle Registration # License # Capacity Vehicle # Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site Refuse Vehicles (# or Units) 0 Dumpsters > 20 cu yd (# of Units) 0 Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler 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 END 46-02-003 Blue Application Form EMERGENCY NOTIFICATI N FOR THIS FACI TY AND/OR PROGRAM CONTACT PERSON r'7 /1 7 Day Ph • „1.2.:—S Night Pl-(?-09)977 ‘L/V PROGRAM ELEMENT (.0"S--- FEE INSPECTOR # c6cic-79 PERMIT VALID if hk /t Check # AMOUNT PAID 2 3 7 El Cash 4 ." REVIEWED BY gipl. Apr ACCOUNTING OFFICE INvoicE # Date Other FEE Food Handler 3°47544 0 Surchargç FEE to P. Date 48-02-034 1/23/13 Adc,e 1-76. 0 Re ,ws rec -liovt MASTERFILE RECORD INFORMATION PINK