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Other FEE <br />Food Handler <br />INvoicE# 3s364i I <br />Date 23 /5- <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />ONew EH Program and New Facility <br />Lo v Av CA T5J-E) <br />and specK size, number of units and pertinent information.) <br />Square Footage Food Handlers Course required: YES 0 No 0 <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 />Sticker # <br />Facility ID ./itc;02.._7/ <br />Y- (Please check the appropriate description <br />Facility Address ce_) cb(Q—E— <br />Mobile Food Vehicle --Make <br />Registration # <br />Program Record ID PRDS-14-SilD e4 <br /> Vehicle Type <br />License # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 I e Plant 0 Produce Stand <br />Special Event---Dates of operation from to CFO Nil A 0 B <br />DAIRY PROGRAM (2000) <br />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) LI 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 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 <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 />0 Kennel <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <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 />C3 Primary Care 0 Acute Care <br />Transfer Station 0 Veterinary Clinic <br />LI Ag/Cannery Waste Site <br />0 Process/Recycle Facility <br />LI Dumpsters > 20 cu yd (# of Units) <br />bitArr, <br />El CIA Lanetill Site 4.711 <br />Farm/Raltati'Weenup SR; <br />4 2023 <br />"'u. • *1444 - • kouler <br />• , I • • .1 • f <br /> License # <br />0 Package Treatment Plant <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units p <br />Sludge/ <br />0 Skilled Nursing 0 Large Generator 0 Small Generat <br />0 Common Storage Facility 0 2 - 10 0 11 -60 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Y-1 rx-a-L—Tc= ,"c\e:-) 0 Day Ph a)ci cf2.-2122(0 Night Ph <br />48-e2-034 <br />1/23/13 lsOLV11157- MASTERFILE RECORt INFORMATION PINK <br />PROGRAM ELEMENT / bo5c-- FEE <br />INSPECTOR # Rot k. e ,P--- PERMIT VALID <br />heck # AMOUNT PAID <br />V 614 REVIEWED BY <br />911712.S <br />40; t <br />_It <br />8 0 Surch <br />to q <br />Date <br />ACCOUNTING OFFICE()