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(SCew EH Program at Existing Facility 0New EH Program and New Facility <br />Facility ID FA Dia277 7g Program Record ID <br />PROGRAM ELEMENT qt;•% y- FEE <br />INSPECTOR # W121-2134-r PERMIT VALID <br />ylAt 0 v (C <br />/check # AMOUNT PAID <br />111E1 Cas4 (REVIEWED BY <br />48-02-034 MASTERFILE RECORD iNFORMATION PINK <br />1/23/13 <br />ACCOUNTING OFFICE tAkrirf ]-21-2.3 <br />C' 0 0 0 Surcharge FT <br />to R. 0 Food Handler <br />Date 1'12112 INVOICE # g <br />Date 7 .23 <br />Other FEE <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />El Dumpsters '7(1 > cu yd (4 of Units) <br />Sludge/ <br />CIA L <br />Farm/ <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility Address '7-3-C ,/0 Ory-, ,A,(3 <br />(Please check the appropriate description and specify size, number 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 />Retail Market----Square footage 0 w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # <br />Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />Temporary Food Facility --Dates of operation from <br />N./ .1,/\ • ( 14 <br />Special Event---Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />El 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 El 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 />El 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 />CI Pumper Yard 0 Package Treatment Plant CI Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />CI Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Small Generator 144144 Ifit95r Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator El <br />O 11 - 60aAN ge ner-Wrs Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form ovviiivsouNry <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM THDEpA,tivi-AL -.TimENT <br /> <br /> Day Ph Night Ph CONTACT PERSON <br />Food Handlers Course required: YES 0 No CI <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />0 CFO 0 A 0 B <br />0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />0 Kennel <br />Capacity Vehicle #