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Date <br />Cash REVIEWED BY Date I ACCOUNTING OFFICE <br />PROGRAM ELEMENT 2221 FEE i,a3 <br />INSPECTOR # PERMIT VALID f? I <br />I=1 Check* AMOUNT PAID VV._ <br />Cesar Ruvalcaba <br />0 Surcharge FEE <br />to '7 t 12o <br />0 Other FEE <br />LI Food Handler <br />INvoicE# 33g <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />LI New EH Program at Existing Facility 0 New EH Program and New Facilit <br />Facility ID 0016960 <br />Program Record ID <br />Facility Address 11901 VV Ripon Rd. 05366 <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 <br />Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br /> <br />CI Mobile Food Vehicle --Make Vehicle Type <br /> <br />Registration # License # <br />Mobile Food Prep Unit-- Make Vehicle Type <br /> <br />Registration # License # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from to <br />Food Handlers Course required: YES 0 No 0 <br />0Vending Machines Number of Units <br />LI Multiple Departments 0 Prepackaged Goods Only <br /> Color <br />Sticker # <br />Color <br />Sticker # <br /> to 0 Ice Plant 0 Produce Stand <br />0 CFO 0,40B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />El Hazardous Materials Business Plan (1900) Number of chemicals: <br />LI CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />LI 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 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site LI 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 /> 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 Vehicle Registration # License # Capacity Vehicle <br />Pumper Yard 0 Package Treatment Plant <br /> 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station LI Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />El Refuse Vehicles (# at units) 0 Dumpsters > 20 cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator <br />Transfer Station 0 Veterinary Clinic El Common Storage Facility 0 2 - 10 <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 Day Ph Night Ph <br />Sludge/Ash Site <br />0 CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />0 Small Generator 0 Limited Hauler <br />0 11 - 60 0 >60 generators <br />MASTERFILE RECORD INFORMATION PINK <br />Cesar Ruvalcaba 1/24/2020 <br />48-02-034 <br />1/23/13