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Facility ID -MOD.Z741-1-7 <br />Facility Address <br />Program Record ID Pk.D5-4)-3-6,1( <br />N /Al -re-41 09-7-7D4//9-(- ,P Ie/W i y Tee <br />PROGRAM ELEMENT 101-1 FEE - 0 Surcharge FEE <br />INSPECTOR # PERMIT VALID Ck 11- 2.3 to - • <br />Check # VI' AMOUNT AMOUNT PAID 7$. 301. OD Date <br />12 Cash <br />48-02-034 <br />1/23/13 <br />REVIEWED BY ACCOUNTING OFFICE <br />MASTERFILE RECORDINFORMATION PINK <br />Other FEE <br />Food Handler <br />INvoicE# _33 7Z <br />Date /3 <br /> <br />to 0CF0 IDACIB <br /> <br />0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />Small Generator 0 Limited Hauler <br />11 - 60 0 > 60 generators <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility w EH Program and New Facility <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 />Retail Market--Square footage q 00.--Cif w/Meat Market only <br />Mobile Food Vehicle --Make <br />Registration # <br />Mobile Food Prep Unit-- Make <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 0 Grade B Dairy <br />CUPA <br />-&171azardous Materials Business Plan (1900) Number of chemicals: 6 <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 />--1E1Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />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 NPUSEP Cleanup Site 0 UIC Site <br />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 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 # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets --Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (4 of Units) 0 Dumpsters > 20 cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <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 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />r EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />(19C(96 CONTACT PERSON N t 19JJ Day Ph goe (r(-6. g.62Nli g ht Ph <br />Vehicle Type <br />Food Handlers Course required: <br />I:Vending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />License # <br />Vehicle Type <br />License # Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />Sticker # <br />Color <br />0 Kennel <br />Capacity Vehicle # <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site