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237 <br />cLO <br />El Surchar e FE <br />to <br />Date <br />1.t_icty 111 Kennel <br />PROGRAM ELEMENT(40%-- FEE <br />INSPECTOR # PERMIT VALID <br />CI Check # AMOUNT PAID <br />)iscash REVIEWED BY ACCOUNTING OFFICE <br />CI Other FEE <br />CI Food Handler <br />INvoicE# 31 D <br />Date /.2- <br />SAN JOAQUIN COUNTY EN\ )NMENTAL HEALTH DEPARTM r <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility CI New EH Program and New Facility <br />Facility ID Fel OO) ts 7 1 Program Record ID 'Pie 057-1-3153 <br />Facility Address /7n U Al 1 0 N sr s-7-75c14_7--D Ai c"- 5.7-0 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 <br />0 Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />0 Retail Market----Square footage El w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />NR/Mobile Food Vehicle --Make T70C\OVe. Vehicle Type \It•-1 Color 010 e-erm <br />Registration # License # 00V 1 Sticker # <br />Mobile 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 El CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy CI Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />Cl CalARP Program CI Program 1 Facility 0 Program 2 Facility El Program 3 Facility <br />Hazardous Waste Generator (2200) > Tons Generated Per Year <br />Tiered Permitting Facility > El CA (2232) El CE (2233, 2234, 2235, 2237) I0 PBR (2231) CI 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 />CI Environmental Assessment CI 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 CI Pool CI Spa 0 Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />0 Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) CI Body Art Facilil-Single Use (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art- ventMobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) pS j P <br />CI Pumper Vehicle Registration # License # Capacit Vehicle # <br />Pumper Yard CI Package Treatment Plant 0 Chemical Toil el nits <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill CI Transfer Station El Ag/Cannery Waste Site kovr p410/Ash Site <br />CI Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility -" SC)P4t <br />SP41.144°Do <br />Ikandfill Site <br />El Refuse Vehicles (# of Units) CI Dumpsters > 20 cu yd (#of units) - Vck - Farm/Ranch Cleanup Site <br />MEDICAL WASTE WASTE PROGRAM (4500) <br />Primary Care CI Acute Care CI Skilled Nursing CI Large Generator 0 Small Generator CI Limited Hauler <br />CI Transfer Station CI Veterinary Clinic El CommOn Storage Facility Cl 2 - 10 CI 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 J2cive- C Lxel- Peok Day Ph (92'5)301 -55 -77 Night Ph <br />48-02-034 MASTERFILE RE •RD I F1RMATION PINK <br />1/23/13