Laserfiche WebLink
Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (# of Units) <br />0 Sludge/Ash Site <br />El CIA Landfill Site <br />El Farm/Ranch Cleanup Site <br />0 Other FEE <br />0 Food Handler <br />INVOICE # 13( <br />Date ct2-/ <br />MASH RFILE RECORD 1 FORMATION PINK <br />.`" <br />I <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />ow EH Pro ram and New Facilit <br />Facilit ID B <br />Facility Address 3099 <br />0 NT TY EPq R7. AL <br />Square Footage Food Handlers Course required: YES la NoqYr <br />0 with Food Preparation OVending Machines Number of Units <br />0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Registration # <br />Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # Sticker # <br />0 Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />0 Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />0 CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />0 Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />0 Tiered Permitting Facility -----> 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />0 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 MMGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPLJSEP Cleanup Site 0 UIC Site <br />0 Abandoned HW Site 0 non-NPLJSEP 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 CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />0 Poultry Farm -----Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />0 Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />0 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 Vehicle Registration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (to or Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 II - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON <br />21t1RIE=OR THIS FACILITY AND/OR PROGRAM <br />a-itnot /* oc Day Ph el /5 -4/3 -0,25g Night Ph <br />PROGRAM ELEMENT, \ FEE SSD <br />INSPECTOR # PERMIT VALS9 — 20- 2S to 9 <br />Check # 30 AMOUNT PAID'/-P 35.6.,(17) Date Lt 2-3 <br />Cash REVIEWED BY ACCOUNTING OFFICE <br />48-02-034 <br />1/23/13 C-k.r\-C2 \o ct <br />(Please check the appropriate description and specify size, number of units and pertinent information.) 141,41/._ ON/vi-COUN <br />FOOD PROGRAM (1600) <br />Er Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market---Square footage <br />Mobile Food Vehicle --Make <br />0 New EH Pro ram at Existin Facilit <br />LJIO 4, SEP <br />Trnckf vel 'TT-06Ni cl 5-31 usv jo4 0 U 20 2023 <br />Nvip? U/N <br />Pro ram Record ID e_o <br />Vehicle Type <br />License # Sticker # <br />Color <br />PAyfi . <br />0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />0 Kennel <br /> <br /> License # Capacity Vehicle # <br /> <br />0 Package Treatment Plant 0 Chemical Toilets ----NuniHr of Units <br />0 Surcharge FEE