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INSPECTOR # <br />REVIEWED BY ACCOUNTING OFFICE <br />PROGRAM ELEMENT 2- c.6& 2•-• FEE -7 <br />AMOUNT PAID El Check # <br />0 Cash <br />PERMIT VALID <br />?>1 I Id • <br />"6—Surcharge FEE <br /> to <br />Date <br />0 Other FEE <br />0 Food Handler <br />3 /1 -7/7-0 INVOICE # <br />Date 3 /1 7[,2.0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />*Iew EH Program at Existing Facility EINew EH Program and New Facility <br />1 F_ay_t_R_AA)p_y D- -C1c-15 Program Record ID pg D 64115-4. <br />Facility Address )10 j2 L i b erhi ez( C--saa Ca 1 S19 5 D--- <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br /> <br />El Restaurant: Seating Capacity <br />Commissary El Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br /> <br />Square Footage Food Handlers Course required: YES El No 0 <br />DI with Food Preparation DIVending Machines Number of Units <br />El w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br /> <br />Vehicle Type Color <br /> <br />Registration # <br />Mobile Food Prep Unit-- Make Vehicle Type <br /> <br />Registration # License # Sticker # <br />El Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce.Stand <br />Special Event---Dates of operation from to 0 CFO DADB <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CU PA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />ED Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />DI Hazardous Waste Generator (2200) > Tons Generated Per Year <br />0 Tiered Permitting Facility > 0 CA (2232) El CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />C:ECAboveground 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 />El Environmental Assessment 0 UST-CAP Site El Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site El non-NPUSEP Cleanup Site El 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 /> El Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) DI Body Art Facility-Single Use (4120) <br />El 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 # <br /> <br />License # Capacity Vehicle # <br />El Pumper Yard El Package Treatment Plant <br /> 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill El Transfer Station El Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />0 Refuse Vehicles (# of Units) El Dumpsters > 20 cu yd (# or Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing El Large Generator <br />El Transfer Station 0 Veterinary Clinic 0 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 /> Day Ph Night Ph <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />License # Sticker # <br />Color <br />0 Sludge/Ash Site <br />El CIA Landfill Site <br />0 Farm/Ranch Cleanup Site <br />0 Small Generator 0 Limited Hauler <br />0 11 - 60 DI >60 generators <br />CONTACT PERSON <br />1/2313