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MASTERFILE INFORMATION FORM (EH 00 69) <br />SAN JOAQUIN COUNTY E'''"IRONMENTAL HEALTH DIVISI -N <br />PAYMENT <br />New EH PrOgram at Existing Facility ONew EH Program and New Facility RECEIVED <br />Facility Address •-bi4 Stte in. <br />MAY 2 8 2003 <br />SAN JOAQUIN COUNTY <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage Food Handlers Course reEnNuViPiRrU°eBNCMIC <br />:ENTYALESHE0ALTHNOloVIS0ION <br />HEALTH SERVICES (Please Check the appropriate description and specify size, number of units and pertinent information.) <br />Commissary 0 Dry storage only 0 with Food Preparation :Wending Machines --Number of Units <br />Retail Market ----Square footage 0 with Meat Market only 0 Multiple Departments 0 Prepacksavd Goods Only <br />fA Mobile Food Vehicle Make c !Ft- v1-pe.41:- Vehicle Type ° Color t4,1 : <br />Registration # License # "-}'-1/4.fireF 2 Sticker # 7./ Ai Ail <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 <br />Special Event --Dates of operation from to 0 Produce Stand <br />DAIRY PROGRAM (2000) <br />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 0 Recycle / Exempt System <br />Tiered Permitting Facility 0 Conditionally Authorized (CA) 0 Conditionally Exempt (CE) <br />0 Permit-By-Rule Fixed Unit 0 Permit-By-Rule Household Hazardous Waste <br /> <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 />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 IIW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned IIW 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 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm ----- --Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Tattooing (4121) 0 Body Piercing (4120) 0 Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle--Registration 4 License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag / Cannery Waste Site 0 Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles --Number of Units 0 Dumpsters > 20 cu yd ----Number of Units 0 Farm/Ranch Cleanup Site <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 EH0069 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON., 04_1, 6 (4)1-)0, r Day PIUW P5() 4/63 y,o/7 Night Ph <br />Faciliiy ID 9 6) hi 7 Program Record ID 1kO5& Iegh 7 <br />PROGRAM ELEMENT I V-51;:, FEE <br /> <br />0 Surcharge FEE 0 Other FEE <br /> <br />INSPECTOR # PERMIT VALID 6--„Qslo to <br />Check # AMOUNT PAID ) Date <br />rA Cash REVIEWED BY VA <04c:2 \'/'? ACCOUNTING OFFICE <br />0 Food Handler <br />INVOICE # <br /> <br />Date <br /> <br />EH 0069 Pink Form Rev. 02/25/03