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Address \()\c._3(:),C)( oNym-e,0A-- S \— <br />and specify size, number of units and pertinent information.) <br />Facility ID <br />(Please check the appropriate description <br />FOOD PROGRAM (1600) <br /> <br />0 Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />New EH Program at Existing Facility <br />'SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />7 Lj <br /> <br />Square Footage <br />0 with Food Preparation <br />w/Meat Market only <br />Program Record ID <br />License # Sticker # <br />Vehicle Type Ai 4_,-Conmevciolor <br />License # k 13 Sticker # 2;7 CC- -7 <br />to 0 Ice Plant 0 Produce Stand <br />Vehicle Type Color <br />to OCF0 0A0B <br />w EH Program and New Facility <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />PAYAIE <br />RECeveo <br />MAY 2 •I (023 <br />SAIV JOAQUIN <br />P v.,,Z AIVIRONAA C°UNT? Qs- DepAi7ITAL <br />WAIT <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Programl 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 />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 />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 <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 /> D Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 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 # <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 (# of units) 0 Dumpsters > 20 Cu yd (# 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 0 Common Storage Facility 0 2 - 10 0 11 - 60 > 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 />Day Ph Night Ph <br />0 Surcharge FEE <br />2-3 to 3 <br />.237. 60 Date 5 <br />ACCOUNTING OFFICE <br />Capacity Vehicle # <br />Sludge/Ash Site <br />CIA Landfill Site <br />0 Farm/Ranch Cleanup Site <br />CONTACT PERSON <br />PROGRAM ELEMENT 6 65 FEE (-) <br />INSPECTOR # PERMIT VALID 5 <br />Check # AMOUNT PAID <br />Cash REVIEWED) <br />Other FEE <br />Food Handler <br />iNvoicE# 3 I 45E- <br />Date 57s 23 <br />48-02-034 MASTERFILE RECORD I ORMATION PINK <br />1/23/13