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Cash REVIEWED BY 48-02-034 MASTERFILE—CORD INFORMATION PINK 1/23/13 PROGRAM ELEMENT /&CDF 4, FEE 't / ;SPECTOR # PERMIT VALID Check # 1 (-) AMOUNT PAID 2,3 LI Surchar. e FEE 3422- to Date ACCOUNTING OFFICE Other FEE Food Handler 2- INvoicE# Date 2,6 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM 0 New EH Program at Existing Faci, y 1:4New EH Program and New Facility ' Facility ID .r)i--5-1) 2-q/(0,co-/oPP Program Record ID u.,„>5--le 163-1- Facility Address E 0 F-el. • IA' v\d",in CA--(152-3ke, (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) Restaurant: Seating Capacity Square Footage Commissary 0 Dry storage only 0 with Food Preparation Retail Market----Square footage 0 w/Meat Market only Mobile Food Vehicle --Make Vehicle Type Registration # License # Sticker # Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand Special Event---Dates of operation from to jzi CFO PI A 0 B DAIRY PROGRAM (2000) El Grade A Dairy CUPA 0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit Hazardous Materials Business Plan (1900) Number of chemicals: CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility Hazardous Waste Generator (2200) >- Tons Generated Per Year Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) Aboveground Storage Tank Facility (AST) (2800) Number of ASTs Underground Storage Tank Program (UST) (2300) Use UST A and B forms 0 Other CUPA Program HOUSING PROGRAM (2400) Hotel/Motel Number of Units 0 Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) Poultry Farm Maximum number of birds TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile,Facility (4131) LIQUID WASTE PROGRAM (4200) PAWS/Mawr. Pumper VehicleRegistration # License # Capacity Vehic Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) MAY 0 8 , ge LO 0 Slud sh Site 0 Landfill 0 Transfer Station 0 Ag/Cannery Waste Site ' 23 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Lap gittiN Coufsp, Refuse Vehicles (# of Units) 0 Dumpsters > 20 cu yd of units) 0 Faniii Vi@itd A MEDICAL WASTE PROGRAM (4500) •F? NEN.). Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 0 > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM )CONTACT PERSONTOAN.tUv1lZ Day Ph j.061 140t (66'1. /Night Ph 1.041 PA I Food Handlers Course required: YES 0 No 0 I:Vending Machines Number of Units 0 Multiple Departments 0 Prepackaged Goods Only Color 0 Kennel