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PERMIT VALID <br />LI Check # AMOUNT PAID <br />LI Cash REVIEWED BY <br />6-1,utk, <br />ACCOUNTING OFFICE <br />CI Food Handler <br />I NVOICE # g34,7 <br />Date <br />to <br />Date <br />INSPECTOR # <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility ONew EH Program and New Facility <br /> <br />Facility ID 'EA 00`Z,`--t 2 '2--7 Program Record ID P/Ro 916 <br />Facility Address 2-s-0,2- k,.) <br />(Please check the appropriate description and specify size, nmber of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 <br />Commissary El Dry storage only 0 with Food Preparation <br /> EVending Machines Number of Units <br />LI Retail Market----Square footage LI w/Meat Market only LI Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Sticker # <br /> to 0 Ice Plant LI Produce Stand <br />to D CFO EADB <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />1=1 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />-ErHazardous Waste Generator (2200) > Tons Generated Per Year Z—'5"' <br />LI CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />LI Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) El PBR (2231) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />D Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />El Other CUPA Program <br />HOUSING PROGRAM (2400) <br />LI 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 />0 Abandoned HW Site LI non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />0 Natural Bathing Area Number of Pools/Spas at Facility 0 Pool LI Spa 0 Out of Service Pool/Spa <br />VECTOR CONTROL PROGRAM (4000) <br />El Kennel Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) El Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) LI 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 />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Sludge/Ash Site LI Landfill 0 Transfer Station LI Ag/Cannery Waste Site <br />CIA Landfill Site LI Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Farm/Ranch Cleanup Site LI Refuse Vehicles (# of Units) 0 Dumpsters > 90 CU yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing D Large Generator LI Small Generator 0 Limited Hauler <br />Transfer Station LI Veterinary Clinic LI Common Storage Facility 0 2 - 10 LI 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 /> <br />LI Mobile Food Vehicle --Make <br /> <br />Registration # <br />1=1 Mobile Food Prep Unit-- Make <br /> <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />Vehicle Type <br />License # <br />Vehicle Type Color <br />License # Sticker # <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAM ELEMENT2-2--2-0 FEE <br /> <br />LI Surcharge FEE LI Other FEE <br /> <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />1/23/13