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New EH Program at Existing Facility <br />Facility ID fi 2J 7 7 <br />New EH Program and New Facility <br />Program Record ID -4.1D zi-g54 <br />0 Food Handler <br />INVOICE #_ <br />Date 7 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br /> <br />Facility Address a et- crl IN)o <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />staurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />1:Pobile Food Vehicle --Make <br /> <br />Registration # <br /> <br />P. Mobile Food Prep Unit-- Make Vehicle Type Color <br /> <br />Registration # License # 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 />El 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 />Poultry Farm Maximum number of birds <br /> 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 # License # 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 O Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility O Process/Recycle Facility <br />Refuse Vehicles (# of units) <br /> <br />• Dumpsters > 20 cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form ritt 0.4p14147.44117}, <br />dIF?rA444,... EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM _ (;) Ls) 3(.12 <br />CONTACT PERSON \"2--\(\c}V\ (\,(A \-/\ Cv\cyc\\ \C\C Day Ph at,Ttik- LAOS —3 'Night Ph tAC) —0 <br />2-3 <br />Square Footage <br />0 with Food Preparation <br />0 w/Meat Market only <br />Vehicle Type <br />License # <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />41 Color f, e <br />Sticker # <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator <br />Transfer Statical El Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 6cti4 4twators <br />2 „ <br />0 Small Generatg4/4 Amited HitOSS <br />Sludge/Aikilfg.A. <br />CIA Larffketki*"./V7* <br />Farm/Rivch Crd'irkkbe <br />e ' <br />PROGRAM ELEMENT s FEE 2- 3 1 0 Surcharge FEE <br /> <br />INSPECTOR # 9S 2-3 PERMIT VALID 2-1123 to 2 <br />LI Check #. AMOUNT PAID $ Date 2— 2 <br />Dif/c V is W REVIEWED BY ACCOUNTING OFFICE 6/06 <br />:lls582W0q0 48-02-0 <br />1/23/13 <br />El Other FEE <br />MASTERFILE RECORD'INFORMATION PINK