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0 Food Handler <br />INVOICE # <br />Date / <br />-4k2b70 % MASTERFILE RECORIO IN ORMATION PINK <br />PROGRAM ELEMENT <br />INSPECTOR # PERMIT VALID <br />Check # AMOUNT PAID <br />CI Cash REVIEWED BY <br />48-02-034 <br />1/23/13 <br />/1 to <br />7/.06 Date <br />ACCOUNTING OFFICE <br />CI Surcharge FEE CI Other FEE <br />SP.k.N JOAQUIN COUNTY 'VIRONMENTAL HEALTH DEPAr '/IENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility ONew EH Program and New Facility <br />Facility ID COI v9 „_, Program Record _I -fg(-6-942/ <br />Facility Address l ,id) Ul [A) .-fr-wq p- tux•fi <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />El Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES CI No CI <br />CI Commissary CI Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />Retail Market----Square footage CI w/Meat Market only 0 Multiple Departments CI Prepackaged Goods Only <br />Eril/lobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # AS,S <br />Temporary Food Facility --Dates of operation from to CI Ice Plant CI Produce Stand <br />CI Special Event---Dates of operation from to CI CFO CI A 0 B <br />PAYRA <br />Retel l/ED <br />JUN <br />SAN <br />u 4 2019 <br />JoAQu n <br />ENviRo c°uN <br />H&ILTH isiMENTA TY bEPARrA, L mesir <br />DAIRY PROGRAM (2000) <br />CI Grade A Dairy CI Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />0 Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program CI 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) CI CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />El Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />CI 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 Fonn <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />CI Environmental Assessment CI UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />CI Abandoned HW Site El 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 CI Spa CI Out of Service Pool/Spa CI 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 />CI Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) <br />CI 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 # License # Capacity Vehicle # <br />CI Pumper Yard CI Package Treatment Plant CI Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill DI Transfer Station El Ag/Cannery Waste Site CI Sludge/Ash Site <br />Waste Tire Facility CI Compost Facility CI Process/Recycle Facility CI CIA Landfill Site <br />CI Refuse Vehicles lft of Units) El Dumpsters > 20 cu yd (# of Units) 1:1 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator CI Small Generator 0 Limited Hauler <br />CI Transfer Station 0 Veterinary Clinic CI 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 />FMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON alt ein D'i n Day Ph Night Ph