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0 New EH Pro ram at Existing Facility <br />41-efl) <br />NNew EH Propram an1J New Facility <br />Program Record ID ?[(-0 (6' 341 Facility ID <br />Square Footage <br />0 with Food Preparation <br />0 with Meat Market only <br /> Vehicle Type <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments0 Prepackaged Goods Only <br />Color <br />MASTERFILE RECORD INFORMATION PINK <br />PROGRAM ELEMENT 1608 <br />INSPECTOR # 8788 <br />1:1 Check # <br />Cash <br />48-02-034 <br />11/15/07 <br />FEE <br /> PERMIT VALID <br />AMOUNT PAID <br />0 Other FEE <br />El Food Han <br />icrtp <br />VOICE# <br />Date s3 <br />o Surc <br />to <br />Date \I 15Pc <br />REVIEWED BY <br />ACCOUNTING OFFICE <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility Address 57 c,r - po wan (-cc q,..C3 31 <br />(Please check the appropriate descript. n andssp‘cify gzi, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market—Square footage <br />Mobile Food Vehicle —Make <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 <br />Special Event Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy <br />CUPA 0 State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />Hazardous Waste Generator Tons Generated Per Year <br />CRT Offsite Handlers (2218) 0 Silver Only (2222) <br />Tiered Permitting Facility 0 Conditionally Authorized (CA) <br />0 Permit-By-Rule Fixed Unit <br />0 Ice Plant <br />0 Produce Stand <br />Recycle/Exempt System (2299) <br />0 Appliance Recyclers (2217) <br />Conditionally Exempt (CE) <br />Permit-By-Rule Household Hazardous Waste <br />0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />0 ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <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 NPLJSEP Cleanup Site 0 UIC Site <br />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 <br /> <br />0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm—Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Tattooing (4121) <br /> <br />0 Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # <br />SOLID WASTE PROGRAM (4400) <br />Refuse Vehicles (# of Units) 0 Dumpsters > 20 cu yd of Units) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Pumper Yard 0 Package Treatment Plant <br /> <br />0 Chemical Toilets —Number of Units j <br />A Landfill Site <br />0 Farm /Ranch Cleanup Site <br />Sludge/Ash S ite <br /> <br />Fcal IENvtioNlml EN. _ <br />HEW VI OLPARTMENI <br />m oivrvIIIN couNTY <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 />CONTACT PERSON An% F7I to-to (-) Day Ph C et).01)63) n-SS Night Phi 8-- <br />0 Kennel _ <br />PAY Win Futgn <br />0 Permanent ClitinGriolg MT22) <br />2°23 Capacity