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FEE <br />PERMIT VALID 11 <br />AMOUNT PAID <br />Cash REVIEWED BY ACCOUNTING OFFICE <br />PROGRAM ELEME <br />INSPECTOR # <br />Check # i4D <br />T /635 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility <br />Et<ew EH Program and New Facility <br />Program Record ID 'FI2L5 1--Egigg <br />-1 <br />and specify size, number of units and pertinent information.) <br />Square Footage Food Handlers Course required: YES 0 No 0 <br />0 with Food Preparation OVending Machines Number of Units <br />w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Facility ID -6AC ,D2-77 /4711--/ <br />Facility Address <br />(Please check the appropriate description <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage a Mobile Food Vehicle --Make NN1 a.. 14.14 <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />to <br />0 Natural Bathing Area <br />0 Kennel <br />0 Chemical Toilets ----Number 410140/%41°N <br />EPAR1MEt41. A4EALTH D <br />SlUdge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />PAY141,‘,EN:r% 0 Body Art Facility-Si 111 ngeE,=Y <br />0 Body Art-Temp EvenrMObile FaciliA (4131) <br />NOV 1 6 2013 <br />Capacity Vehicle # COUNTI <br />CONTACT PERSON t--k.:‘,5 <br />Vehicle Type rf «-,\ <br /> <br />Color <br />License # C.25 1 („, ‘..)3 <br /> <br />Sticker # <br />Vehicle Type Color <br />License # Sticker # <br />0 Ice Plant 0 Produce Stand <br />to El CFO El A 0 B <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 />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />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 0 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 0 Pool 0 Spa 0 Out of Service Pool/Spa <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # <br />Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br /> O Ag/Cannery Waste Site <br />Process/Recycle Facility Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of units) <br /> <br />O Dumpsters > 20 cu yd (# 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 />2c4-100 -g4-51 Day Ph (1.2C11C0--)'`-t 3 1 Night Ph <br />Other FEE <br />Food Handler <br />INVOICE # <br />Date <br />48-02-034 <br />1/23/13 <br />MASTERFILE RECORD INFORMATION PINK