Laserfiche WebLink
48-02-034 <br />1/23/13 <br /> <br />'ID Surchr ge F E El Other FEE <br />to (f2 t90 0211 0 Food Handler <br />Date (R1 ) INVOICE # 3 17 3 <br />ACCOUNTING OFFICE (111V zigt iate <br />MASTERFILE REOR9 INFORMATION PINK <br />PROGRAM ELEMENT 1681 FEE <br />INSPECTOR # 9828 PERMIT VALID <br />ILk 9tb3ly <br />Check # AMOUNT PAID <br />h von REVIEWED BY 7_S <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility <br /> EINew EH Program and New Facility <br />Facility ID FA <br /> <br />Program Record ID FRD5+S L j <br />Facility Address 110 N EL DORADO ST <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br /> <br />0 Restaurant: Seating Capacity <br /> Square Footage <br />0 Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />Mobile Food Vehicle --Make <br /> <br />Registration # <br />Mobile Food Prep Unit-- Make <br /> <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <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 />El 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 />El Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />El 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 # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles 18 of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator LI dlovo <br />LI Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 -60 Si:1p j>060 gen <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form 41/41QUIN <br /> <br />, ,... <br /> <br />EMERGENCY NOZIFICATION FOR THIS FACILITY AND/OR PROGRAM OA*OUN <br />L), CONTACT PERSON :)14'QnlIA.V02._ ETY1034e-4 6-e- Day Ph Sect Night Ph 81"1741( r <br />Food Handlers Course required: YES El No El <br />I:Vending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Vehicle Type Color <br />License # Sticker # <br />Vehicle Type Color <br />License # Sticker # <br />to El Ice Plant 0 Produce Stand <br />to El CFO 0 A El B <br /> License # <br />El Package Treatment Plant <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (4 of Units) <br />Sludge/Ash kt _ <br />El CIA Landi ettr41441 <br />Farm/Ra <br />uler <br />ra4)