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ACCOUNTING OFFICE Date 6 2A <br />(.0 48-02-034 <br />1/23/13 1011727Z. MASTERFILE RECORD INFORMATION PINK <br />PROGRAM ELEMENT 36 FEE <br />INSPECTOR # 9 8 2- 0 PERMIT VALID <br />Check # AMOUNT PAID <br />1:1 Cash REVIEWED BY <br />0 Surchar e F E CI Other FEE <br />to CI Food Handler <br />Date INVOICE # <br />SAN, JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />UgNew EH Program and New Facility <br />Facility ID ROD,277 <br /> <br />Program Record ID re.(1C-1-1-SLI"cf4' <br />Facility Address \ LC) C ),C• (‘•-rk. C)A (it 1c--:):-2-A1' <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 0 No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />Retail Market---Square footage El w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />CI Mobile Food Vehicle —Make Vehicle Type Color <br />Registration # License # Sticker # <br />CI Mobile Food Prep Unit— Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility —Dates of operation from to 0 Ice Plant CI Produce Stand <br />CI Special Event--Dates of operation from to 0 CFO 0 A CI B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy CI Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />CI Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program CI Program 1 Facility CI Program 2 Facility CI Program 3 Facility <br />Hazardous Waste Generator (2200) -->-Tons Generated Per Year <br />CI Tiered Permitting Facility CI CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231)II <br />ILJWOAQ.UAT <br />023 <br />ED <br />N COUI"NTY <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />6) <br />0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ECEIV <br />CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program JUN 1 3 2 <br />Hotel/Motel ----Number of Units <br /> <br /> 0 Jail or Exempt Institution --Nun)biskJ9114601.4EN.f.AL <br />IlEALTH DEPARTMENT <br />HOUSING PROGRAM (2400) SAN <br />II <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />CI Environmental Assessment CI UST-CAP Site I=1 Local HW Cleanup Site CI NPL/SEP Cleanup Site 0 UIC Site <br />CI Abandoned HW Site El non-NPLJSEP Cleanup Site CI RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (300) <br />Number of Pools/Spas at Facility I g Pool CI Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />CI Poultry Farm----Maximum number of birds CI Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />CI 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 />CI Pumper VehicleRegistration # License # Capacity Vehicle # <br />CI 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/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (# of Units) CI Dumpsters > 90 CU yd (# of Units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing El Large Generator 0 Small Generator 0 Limited Hauler <br />ID Transfer Station CI Veterinary Clinic CI Common Storage Facility 0 2- 10 0 11 -60 0 > 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 />New EH Program at Existing Facility <br />CONTACT PERSON