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PROGRAM ELEMENT 11135 FEE *2 <br />INSPECTOR # PERMIT VALID <br />Check # AMOUNT PAID <br />dcik,Vjf,j REVIEWED BY <br />OierklAc3#: L2S-(51-bn6 <br />to <br />Date <br />ACCOUNTING OFFICE <br />LI Surchar e FEE 0 Other FEE <br />48-02-034 <br />1/23/13 <br />0 Food Handler <br /> <br />INVOICE # 3g 17 1-1-5- <br />Date 6 /2 23 <br />MASTERFILE R CORD rNF0RMATI0N PINK <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility <br />Facility ID F-7 0D277c <br />0 New EH Program and New Facility <br />Program Record ID -?0SLI---S410, <br />Facility Address V1-0 5- SaCi41, VVU2/40-0 el,"1 . Lo1. 0152.40 <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 <br />Commissary 0 Dry storage only 0 with Food Preparation <br />El Retail Market----Square footage 0 w/Meat Market only <br />XMobile Food Vehicle --Make <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to 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 />0 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 />El 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 />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 # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br /> Vehicle Type Color <br />License # 2- Sticker # <br />Vehicle Type Color <br />License # <br />0 Kennel <br />SOLID WASTE PROGRAM (4400) <br />Transfer Station <br />Compost Facility <br />0 siudge/APAYMENT Ag/Cannery Waste Site <br />Process/Recycle Facility 0 CIA Lantaftelwr% <br />Dumpsters > 20 cu yd (# of Units) 0 Farm/Ranch CleanupaVtt <br />0 Small Generator <br />0 11 - 60 <br />DEPARTMENT <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM ' <br />CONTACT PERSON mclooi Day Ph1O7 c.)0- 0-2, Night POO <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form HEALTH MrTAL <br />Landfill <br />Waste Tire Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) JUN 0 9 2023 <br />jmited Hauler <br />f24:1INTY <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10