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Facility Address 7 Vi R.) S (it <br />(Please Check the appropriate description and specify number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity Square Footage <br />Commissary 0 Dry storage only 0 with Food Preparation <br />0 Retail Market —Square footage 0 with Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />Registration if License if Sticker if <br />Mobile Food Prep Unit—Make Vehicle Type Color <br />Registration # License if Sticker if <br />Temporary Food Facility ---Dates of operation from to 0 Ice Plant <br />Special Event —Dates of operation from to 0 Produce Stand <br />DAIRY PROGRAM (2000) <br />0 Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser—Number of Containers in Multi-Head Unit <br />CUPA 0 State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />0 Hazardous Waste Generator-------Tons Generated Per Year <br />0 CRT Offsite Handlers (2218) <br />Tiered Permitting Facility <br />0 Recycle! Exempt System (2299) <br />0 Silver Only (2222) 0 Appliance Recyclers (2217) <br />0 Conditionally Authorized (CA) 0 Conditionally Exempt (CE) <br />0 Permit-By-Rule Fixed Unit 0 Permit-By-Rule Household Hazardous Waste <br />0 ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br />0 Hotel/Motel —Number of Units 0 Jail or Exempt Institution —Number of Units <br />Employee Housing (2700) Use Employee HousineLabor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />0 Environmental Assessment 0 UST-CAP Site 0 Local IIW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />0 Abandoned IIW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site E Water Quality Romeo:nation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 out of Service Pool/Spa <br />VECTOR CONTROL PROGRAM (4000) <br />0 Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />0 Tattooing (4121) 0 Body Piercing (4120) 0 Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle—Registration if License # Capacity Vehicle # <br />0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) <br />0 Landfill <br />0 Waste Tire Facility <br />0 Refuse Vehicles --Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility-0 2 - 10 ------0 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 Day Ph Night Ph <br />0 Transfer Station 0 Ag / Cannery Waste Site 0 Sludge/Ash Site <br />0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br /> 0 Dumpsters >20 cu yd --Number of Units 0 Farm/Ranch Cleanup Site <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines —Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />co066 <br />z0000 (“7 <br />siz_FoK <br />Natural Bathing Area <br />SAN JOAQUIN COUNTY Em vIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility ONew EH Program and New Facility <br />Facility ID <br /> <br />Program Record ID <br />0 Other FEE PROGRAM ELEMENT 2-- (11 S FEE 0 Surcharge FEE <br />REVIEWED BY ACCOUNTING OFFICE <br />INSPECTOR # LC& 9 6 D <br />0 Check # AMOUNT PAID Date <br />Cash <br /> 0 Food handler <br />INVOICE # <br />Date <br />PERMIT VALID to <br />48-02-034 Masterfile Record Pink