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0 Other FEE <br />0 Food Handler INSPECTOR # 55 PERMIT VALID <br />Check # AMOUNT PAID <br />Cash REVIEWED SY I ta.SeLtitt <br />48-02-034 <br />1/23113 <br />ACCOUNTING OFFICE <br />Date Olt 0,1) INVOICE # <br />Lb Date 2- / <br />MASTERFILE RECORD INFORMATION PINK <br />9/grarcharge FEE <br />to <br />PROGRAM ELEMENT )...)J,0 FEE MR <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility Alew EH Program and New Facili y <br />Facility ID PAD° 2-67c Program Record ID 1205745 <br />Facility Address q It Li.ce ,--,N).e_ '+ Mt:to-it-cc, Ca q"5337 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only El Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />0 Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />El Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce,Stand <br />El Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />LI CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />azardous Waste Generator (2200) > Tons Generated Per Year 5 ..trA <br />Tiered Permitting Facility > 0 CA (2232) El 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 />LI 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 F01171 <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site D Local HW Cleanup Site 0 NPL/SEP Cleanup Site El UIC Site <br />Abandoned HW Site 0 non-NPUSEP 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 D Out of Service Pool/Spa D Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds D 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) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />LI Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard El Package Treatment Plant El Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill El Transfer Station LI Ag/Cannery Waste Site LI Sludge/Ash Site <br />1=1 Waste Tire Facility 0 Compost Facility El Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (# of units) LI Dumpsters > 20 cu yd (# of Units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care LI Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station El Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 LI > 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