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PROGRAM ELEMENT 1632-- - ; — -----$-0 , EE <br />INSPECTOR # 9828 PERMIT VALID <br />0 Check // AMOUNT PAID <br />0 Cash REVIEWED BY <br />48-02-034 <br />1/23/13 <br />to <br />Date <br />UNTING OFFICE <br />0 Surcha ge F E 0 Other FEE <br />MASTERFILE RE RD IN ORMATION PINK <br />ID Food Handler <br />INvoicE# <br />Date 7 4 7/3- <br />ECEINIED <br />MAR 29 2023 <br />ENVIRONMENTAL <br />HEALTH PERMIT/SERVICES <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existin Facility New EH Program and New Fa ility <br />Facility ID FACC)2-7 Program Record ID <br />Food Handlers Course required: YES 0 No 0 <br />ClVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Facility Address Address 820 N. AMERICAN ST. <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 <br />0 Commissary 0 Dry storage only 0 with Food Preparation <br />El Retail Market----Square footage 0 w/Meat Market only <br />0 Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />0 Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />0 Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />0 Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers In Multi-Head Unit <br /> <br />0 Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility <br />0 Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />0 Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) <br />0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 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 0 UIC Site <br />0 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 <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />D Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />0 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 />0 Pumper VehicleRegistration # License # Capacity Vehicle # <br />Pumper Yard El Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site <br />0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (Poi units) 0 Dumpsters > 20 Cu yd (fi of Units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />0 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2- 10 ;JD 11 -60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMER ENCY NOTIFICATION FOR THIS FACILITY AND/ORPROGR <br />CONTACT PERSON I'M Day Ph 7401 ‘"b' ight Ph <br />0 Program 3 Facility <br />PBR (2231) 0 PBR HHW (2236) <br />0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />CI Kennel <br />I