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48-02-034 <br />1/23/13 <br />MASTERFILE R COR INFORMATION PINK <br />PROGRAM ELEMENT 1681 FEE 5237.00 Surca <br />INSPECTOR # 9828 PERMIT VALID f3P-11/43 to ,5 <br />.&A---" AMOUNT PAID - , Date <br />ALOUNTING OFFICE REVIEWED BY <br />I/Et_ 0 Other FEE <br />2— 0 Food Handler <br /> INVOICE # <br />Date 3 22_ <br />Check # <br />Cash <br /> 1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility ElNew EH Program and Newacility F <br />Facility ID 2",400 S-13 Pro <br />110 N Fi DORADO ST <br /> Vehicle Type <br />Registration # License # <br />Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # Sticker # <br />0 Temporary Food Facility --Dates of operation from to 0 Ice Plant D Produce Stand <br />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 />C3 Hazardous Materials Business Plan (1900) Number of chemicals: <br />LI CalARP Program C3 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) 0 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 Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPLISEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPLISEP Cleanup Site 0 RWOCB Cleanup Site LI 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 0 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 />El Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) ID Body Ar-t 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 VehicleRegistration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (it or urnts) 0 Dumpsters > 20 Cu yd (# or units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited <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 />CONTACT PERSON Day Ph Night Ph <br />(Please check the appropriate description and specify size, <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br />Facility Address <br />Square Footage <br />with Food Prep <br />LI w/M <br />f$*n lifl4T <br />v at) <br />----ramRecord ID 335— SA <br />N 2 0 <br />2023 <br />E-rv v`ifsl c 6,4 1. Orvioe. OuN7.‘, <br />number of units and pertinent information.) D6PARA17-7-4 L <br />Food Handlers Course required: YES LI No El <br />aration :Wending Machines Number of Units <br />eat Market only LI Multiple Departments El Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />Hauler