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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMAT7F_QRM <br />Facility ID F---4,02in„,-7, Program Record ID Fkq.5-1/-7 1-t-S7f <br />Facility Address -55 (N) A eD C 52_0s <br />New EH Program at Existing Facility New EH Program and New Facility <br />o Surcha ge EE <br />to St <br />Date C"-Air 2 3 <br />ACCOUNTING OFFICE <br />Other FEE <br />Food Handler <br />iNvoicE# 3 gle564- 13 <br />a41- Date <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <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 /> <br />Registration # <br />Mobile Food Prep Unit-- Make <br /> <br />Registration # <br />El Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />( <br />-ll <br />-5k) Ot- AkA.c.,,1- ' <br />DAIRY PROG <br />i <br />AM (2000) <br />Grade A Dairy <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility <br />Hazardous Waste Generator (2200) >- Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />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 <br />Employee Housing (2700) Use Employee <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP ClearbaltMEWIC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water bib? ' ion Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br /> <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa alat, Ming Area <br />YAInmecourrrY <br />SAN <br />ENVIRONMENTAL T <br />LTH DEPARTMEN <br />Body Art Facili Ingle Use (4120) <br />0 Body Art-Temp Event Mobile Facility (4131) <br />Ag/Cannery Waste Site <br /> O Sludge/Ash Site <br />Process/Recycle Facility <br /> O CIA Landfill Site <br />Dumpsters > 20 cu yd of Units) <br /> O Farm/Ranch Cleanup Site <br />0 Common Storage Facility 0 2- 10 0 11 -60 0 > 60 generators <br /> Square Footage <br />0 with Food Preparation <br /> 0 w/Meat Market only <br /> Vehicle Type <br />License # Sticker # <br /> <br />Vehicle Type Color <br /> <br />License # Sticker # <br /> to 0 Ice Plant 0 Produce Stand <br />to 0 CFO 0 A 0 B <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />0 Program 3 Facility <br />0 PBR (2231) 0 PBR HHW (2236) <br />0 Jail or Exempt Institution ----Number of Units <br />Housing/Labor Camp Application Form <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # <br />Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <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 <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />' <br />)vu J,EvM,ERGENCY OTTICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON bSo <br />t <br />Day P oqC Q -vo 17) Night Ph <br />PROGRAM ELEMENT Lf FEE <br />INSPECTOR # CO7A ' 3 PERMIT VALID <br />Check # AMOUNT PAID <br />p(Cash REVIEWED BY <br />48-02-034 MASTERFILE R CORI INFORMATION PINK <br />1/23/13