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0 Other FEE CI Surcharge FEE PROGRAM ELEMENT FEE 4 <br />INSPECTOR # PERMIT VALID <br />Check # AMOUNT PAID7b 2 <br />Cash REVIEWED BY ACCOUNTING OFFICE <br />to 3/, <br />Date HAM; <br />/,14 <br />1:1 Food Handler <br />INVOICE # <br />Date 11 .77 <br />PAYMENT <br />RECEIVED <br />ivoV 0 1 2019 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL <br />S?!1/4 /%1 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />CI New EH Program at Existin • Facility ONew EH Prozam and New Facility <br /> <br />Facility ID , 67)-- Pro ram Record ID <br /> '?-ier7(7 <br />U\323 <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 <br />CI Commissary 0 Dry storage only El with Food Preparation El Vending Machines Number of Units <br />El Retail Market----Square footage El w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # 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 0 CFO 0 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 />El CalARP Program 0 Program 1 Facility 0 Program 2 Facility CI Program 3 Facility <br />CI Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />CI 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 />CI Environmental Assessment 0 UST-CAP Site CI Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />CI Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site CI 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 /> CI 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) CI 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 />CI Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM <br />CI Landfill <br />Waste Tire Facility <br />CI Refuse Vehicles (# of <br />(4400) <br />Transfer Station <br />Compost Facility <br />Units) <br />Ag/Cannery Waste Site <br />CI Process/Recycle Facility <br />El Dumpsters > 20 cu yd (# of units) <br /> <br />CI Sludge/Ash Site <br />CI CIA Landfill Site <br />0 Farm/Ranch Cleanup Site <br /> <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator <br /> <br />0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic CI Common Storage Facility 0 2-10 0 1 1 - 6 0 <br /> 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 />Facility Address iopo 16171, <br />(Please check the appropriate description and specify sr e, number of units and pertinent information.) <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />1/23/13