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El Ag/Cannery Waste Site <br />0 Process/Recycle Facility <br />0 Dumpsters > 20 cu yd of units) <br />Cl Sludge/Ash Site <br />CI CIA Landfill Site <br />0 Farm/Ranch Cleanup Site <br />ACCOUNTING OFFICE L13 <br />MASTERFILE RECORD INFORMATION PINK 48-02-034 <br />PROGRAM ELEMENT 1 22-0 FEE <br />tnUrl, PERMIT VALID <br />AMOUNT PAID <br />REVIEWED BY <br />I=1 Surcharge FEE lit <br /> to <br /> <br />Date <br />i <br /> /,2-3/ >t) <br />11:1 Other FEE <br />0 Food Handler <br />INVOICE # <br />Date <br />A. <br />22-t--) 2V26 INSPECTOR # <br />Check # <br />Cash <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Food Handlers Course required: YES 0 No CI <br />OVending Machines Number of Units <br />0 Multiple Departments CI Prepackaged Goods Only <br /> Color <br />Sticker # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />0 New EH Program at Existing Facility <br />Facility ID riA-00,2 q-1 <br />ONew EH Program and New Facilit <br />Program Record ID PP. (3 5 .2s". <br />Facility Address (1C; 1 • <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />Commissary CI Dry storage only 0 with Food Preparation <br />Retail Market----Square footage El w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # <br /> <br /> Vehicle Type Color <br /> <br />License # <br /> <br />Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />to 0CF0 OACIB <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 />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />VI Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />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 />0 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 />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site CI UIC Site <br />El Abandoned HW Site 0 non-NPLJSEP 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 CI Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />CI Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) CI 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 />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 />CI Landfill CI Transfer Station <br />CI Waste Tire Facility CI Compost Facility <br />Refuse Vehicles (# of units) <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 EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> <br />Day Ph -2-el (r -'01'2(.' Night Ph CONTACT PERSON 7Q(K110 CI <br />1/23/13