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SAN JOAQUIN COUNTY E ONMENTAL HEALTH DEPART: AT <br />MASTERFILE RECORD INFORMATION FORM <br />Ei New EH Program at Existing Facility ew EH Program and New Facility <br />Facility ID p-A,00.2_14-1-74)- Program Record ID <br /> <br />PROGRAM ELEMENT ( 3 FEE <br />INSPECTOR # get g 7 PERMIT VALI <br />Check # AMOUNT PAID <br />El Cash REVIEWED BY ACCOUNTING OFFICE <br />0 Surchar• - F <br />to <br />Date 2,j <br />El Other FEE <br />0 Food Handler <br />INVOICE # C2 7 <br />Date <br />P44 <br />/4- 414 C ile <br />(Please check the appropriate description and specify size, number of units and pertinent information.)"<iiiiiiV/P,e°47.), <br />FOOD PROGRAM (1600) ei947;14 <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />?'Mobile Food Vehicle --Make 1\0 Fre_cf0 Es <br />P 5 Registration # P 74 z...:33550-to <br />Sticker # <br /> to El Ice Plant 0 Produce Stand <br /> to OCF0 CIA0B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />0 Grade B Dairy CI Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program 0 Program 1 Facility 0 Program 2 Facility Cl Program 3 Facility <br />Hazardous Waste Generator (2200) > Tons Generated Per Year <br />El 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 />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units CI 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 El Local HW Cleanup Site 0 NPLJSEP Cleanup Site 0 UIC Site <br />Abandoned HW Site El non-NPL/SEP Cleanup Site CI 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 CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br /> <br />CI Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) CI 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 />El Pumper VehicieRegistration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant CI Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill CI Transfer Station El Ag/Cannery Waste Site O Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility El Process/Recycle Facility O CIA Landfill Site <br />Refuse Vehicles (# of Units) <br /> El Dumpsters > 20 cu yd (# of Units) <br />O Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />El Primary Care El Acute Care CI Skilled Nursing CI Large Generator El Small Generator 0 Limited Hauler <br />Transfer Station El Veterinary Clinic 0 Common Storage Facility CI 2 - 10 <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 PERSO Savsi zgperiz.. Ros 4 l'-'71'75s:gy Ph 06g0 Night Ph 001 5'1.5 76W1 <br />48-02-034 <br />1/23/13 75-6?6,670 MASTERFILE RECORD INFORMATION PINK <br />Facility Address 500 -71-1" 57- i P, txpf -c-o , 4/1 <br />''Quitv <br />I R v <br />414•,/, <br />Square Footage Food Handlers Course required: YES LI''No 0 <br />0 with Food Preparation I:Vending Machines Number of Units <br />w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />Vehicle Type 5Fizir-ITSIZ V P-Ni•J Color tr6-0,4-1- 6-7-7FP <br />License # cr1.5 e Sticker # <br />Color <br />0 11 - 60 0 >60 generators