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Food Handler <br />3 INVOICE # <br />Date /6 <br />MASTERFILE RE OR INFORMATION PINK <br />&S5 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />ONew EH Program and New Facility <br />Facility Address "771 /9.1/ 7171 Siree,7 4- ri2at0S-7 4-0 '53cS7 <br />(Please check the appropriate description and specify size, number of units and pe4inent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br /> <br />V' 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 0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit <br />CUPA <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 LI 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 0 Kennel <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 />PAYMENT <br />License # Capacity <br />0 Package Treatment Plant 0 Chemical Toilets ----Numbernits <br />U Sludge/Ash Site Ag/Cannery Waste Site <br /> JOCT 0 6 2023 <br />CDDMItiltilrgigNP Process/Recycle Facility <br />IMMIfirr up Site Dumpsters > 20 cu yd (tt or Units) <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 <br /> <br />O 11 - 60 0 >60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />%New EH Program at Existing Facility <br />Facility ID Fiti 0016758-ci Program Record ID Ro51 FE 7+0 <br />License # V&-0 <br /> Vehicle Type <br />License # <br /> Square Footage <br />0 with Food Preparation <br /> 0 w/Meat Market only <br />Vehicle Type <br />to <br />to <br />Food Handlers Course required: YES 0 No 0 <br />[Wending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br /> Color <br />Sticker # <br />Color <br />Sticker # <br /> 0 Ice Plant 0 Produce Stand <br />0 CFO 0 A 0 B <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />__________ <br />Landfill <br /> <br />O Transfer Station <br />Waste Tire Facility O Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br /> <br />E ERGEN NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph Ck viNight Ph CONTACT PERSON <br />PROGRAM ELEMENT ir& 3 FEE <br />INSPECTOR # , PERMIT VALID 0 6/2•3 <br />&Check # ( AMOUNT PAID 11 Date <br />Cash REVIEWED BY ACCOUNTING OFFICE <br />48-02-034 <br />1/23/13 <br />VI< *6 eRraiii <br />0 Surcharge FEE <br /> <br />Other FEE <br />