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MASTERFILE RECORD INFORMATION PINK <br />PROGRAM ELEMENT <br />INSPECTOR # <br />El/Check # <br />C <br />FEE <br />PERMIT VALID <br />AMOUNT PAID <br />0 Surcharge FE <br />2-32 to 12--r31 <br />ACCOUNTING OFFICE <br />0 Other FEE <br />LI Food Handler <br />INvoicE# <br />Date 5 <br />'7 <br />23 REVIEWED BY <br />48-02-034 <br />1/23/13 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />CI New EH Program at Existing Facility <br /> NI New EH Program and New Facility <br />Facility ID Program Record ID 1405..-:+gl-Ko3 <br />Facility Address <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES El No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />LI w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />vE,22/ <br />a2-3 <br />Vehicle Type r/47/04/,LEA Color 1,41/ 7. <br />License #y.2.qc1229Sticker # <br />Color <br />Sticker # <br />0 Ice Plant 0 Produce Stand <br />DAIRY PROGRAM (2000) <br />LI Grade A Dairy <br />CUPA <br />0 Grade B Dairy 1=1 Milk Dispenser -Number of Containers in Multi-Head Unit <br /> <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 />LI Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />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 LI 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 />Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />0 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 />1=1 Pumper VehicleRegistration # License # Capacity Vehicle # <br />LI Pumper Yard 171 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />1=1 Waste Tire Facility El Compost Facility <br />Refuse Vehicles (8 of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 -. 0 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON fgri -rt/,/-1. Day Ph 2 P9--‘72-17/41\light Ph 29--tia--....172‘: <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />LI Retail Market----Square footage <br />Mobile Food Vehicle --Make <br />Registration # <br />Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />Temporary Food Facility --Dates of operation from to <br />Special Event---Dates of operation from to 1=1 CFO DA0B <br />0 Kennel <br />0 Chemical Toilets ----Number of Units <br />LI Ag/Cannery Waste Site <br />0 Process/Recycle Facility <br />LI Dumpsters > 20 cu yd (8 of Units) <br />LI Slud MEW <br />LI CIA cent, <br />LI Farritauch CleaWdidSite <br />LI <br />1"1 3 2n2, <br />Small GenergtOgt Wmited-Pihdler <br />0 11 - gkEN 444 gerwevrs itri/06, ENTAL ithermENr