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LI Surcharge FEE 0 Other FEE <br />El Food Handler <br />7,3 <br />to <br />Date <br />ACCOUNTING OFFICE <br />PROGRAM ELEMENT t FEE <br />INSPECTOR # PERMIT VALID <br />Elheck # AMOUNT PAID <br />C h eald REVIEWED BYC,•...A. <br />12- 31123 <br />I 2o 23 INVOICE# 3 7 OTh 0)— Date 2_ <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility 0New EH Program and New Facility <br />Program Record ID P/0 4-g,21)/ Facility ID F -40r),),7 51) I <br />Facility Address I 3C) I <br />(Please check the appropriate description and <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />Commissary 0 Dry storage only 0 with Food Preparation <br />0. Retail Market----Square footage 0 w/Meat Market only <br />a-Mobile Food Vehicle --Make /VOZ M A Vehicle Type <br />Registration # License # (4 <br />CI Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepacka_ued Goods Only <br />P\ /K Color IC< <br />u F (1,5 S 72- Sticker # <br />Temporary Food Facility --Dates of operation from to <br />Color <br />Sticker # <br />0 Ice Plant 0 Produce Stand <br />at Y aim PJ20 ST L'pr cp 95 2-9 0 <br />specify size, number of units and pertinent information.) <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />ID Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />LI CalARP Program 0 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 />El 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 />CI Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP 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 0 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) C3 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 />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 0 SIudgPi&7Art. <br />0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA arVetelf4ityliz,„' <br />Refuse Vehicles (# of units) CI Dumpsters > 20 cu yd of units) 0 Farm/Ranch dielnVaite <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small GeneraitiVVP)4mited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2- 10 El 11 - 6/441.A.Ptt'Weej*ozs <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form 111 D.B847.mti ' <br />O <br />DclE,ERGENCY NOTIFI ATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON il Day Ph 2 (2, C1 30.2i 3 C),- Night Ph <br />2 c1 -3o- -302_ <br />MASTERFILE RECORD INFORMATION PINK 48-02-03 <br />1/23/13