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PROGRAM ELEMENTi 6, 3 3 FEE 1i of Surcha <br />INSPECTOR gj PERMIT VALID to /2 <br />0/Check #, AMOUNT PAID it a, Date <br />C h 05H- REVIEWED BY <br />lunftql- <br />ACCOUNTING OFFICE UPI' <br />MASTERFILE RECORD D1FORMATION PINK <br />Other FEE <br />Food Handler <br />INVOICE # Sg/1-21 <br />Date 3( <br />48-0 -034 <br />1/23/13 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility Mew EH Program and New Facility <br />Facility ID F 4032-7 4n Program Record ID Pk,eD <br />Facility Add ress 736 —C. (0--/i • )/./1/ e4 cV-Dee-J-0 NJ? <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 />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to <br /> <br />0 CFO 0 A 0 B <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 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 />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 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />0 Kennel El 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) 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 /> 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 Sludge/ <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA La 1E:'Afr <br />Refuse Vehicles of of units) 0 Dumpsters > 20 cu yd of of units) 0 Farm/Ran site <br />MEDICAL MEDICAL WASTE PROGRAM (4500)1,Viciy - 4=0 <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small GeneratzgA H Limdea Itnilgr <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 .v_initeivgense'ritArs <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form • (EQ.,. ON COu 1 bi MEN NT), <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM , _, ,..,—,Tiiii.A.... <br />CONTACT PERSON Fedelge i) io,c,c ,1/4 Day Ph (---('e(1)‘- 6. 2 -(11 iilight Ph ( 7 c ) Jui;.? —'1113 <br />dq_S-e3 <br />Square Footage <br />0 with Food Preparation <br />0 w/Meat Market only <br />Vehicle Type <br />License # qv g-51.3 <br /> Vehicle Type <br />License # <br />Food Handlers Course required: YES 0 No 0 <br />0Vending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br /> Color <br />Sticker # <br />Color <br />Sticker #