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0 Surcharge EE <br />10 30 <br />Date <br />ACCOUNTING OFFICE <br />MASTERFILE OR INFORMATION PINK <br />Food Handler <br />INVOICE :7 <br />Date <br />Other FEE <br />J10111r, AI • III g •••1.11 41111.1.1 II.% I • 11•• <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility kiirlew Ell Program and New Facility <br />Facility ID ri 00.2:737).— Program Record ID <br />Facility Address \-1-Sa) sAver- Way_, \__a JO? <br />(Please check the appropriate description and specify size, number of units and pertinent Information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity Square Footage <br />0, Commissary 0 Dry storage only 0 ‘‘1111 Food Preparation <br />0' Retail Market----Square footage 0 w/Meal Markel only <br />Mobile Food Vehicle --Make Vehicle Typo <br /> <br />Registration # License II <br />Mobile Food Prep Unit-- Make Vehicle Typo Color <br /> <br />Registration # License II Slicker t/ <br />0 Temporary Food Facility --Dates of operation from to I=1, Ice Plant 0 Produce Stand <br />0 Special Event—Dales of operation from to 37,4SFO A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUP:. <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />0 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 />HoteIrMotel —Number of Units 0 Jail or Exempt Institution --Number of Units <br />Employee Housing (2700) Use Employee Housino/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 NPIJSEP Cleanup Site 0 UIC Site <br />0 Abandoned HW Site 0 non-NPUSEP 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 />CI Body Art Practitioner Reg (4110) El Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (-1120) <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 II License II Capacity Vehicle t/ <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 AgICannery Waste Site 0 Sludge/Ash Site <br />0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles to of Uftls) Dtimpsters > 20 cu yd pr Un Is) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Caro 0 Acute Care 0 Skilled Nursing 0 Largo Generator 0 Small Generator 0 Limited Hauler <br />0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS OM 46-02-003 Blue Application Font; <br />MERGE Icy NOTIFICATION FOR TIIIS FACILITY AND/on PROGRAM <br />CONTACT PERSON Kkaid01 E.‹.\(\\ (Air Day Ph ciac-A_SR_Q\ g- Night Ph 0‘2c--.\--n0lt4 <br />3 <br />AUG 2 9 2023 <br />SAN <br />JOA QU/N COUNTY ENVIRON <br />MENT AL HEALT DEPARTAIEN7- <br />Ce3 <br />Food Handlers Course required; YES 0 rio 0 <br />['Vending Machines Number of Units <br />0 Multiple DepartrnentsPrepackaged Goods Only <br />Color <br />Slicker // <br />PROGRAM EFMENT (ecii-c—WE- <br />INSPECTOR L fr'€ C PERMIT VALID <br />Check I/ AMOUNT PAID <br />CI Cash REVIEWED BY <br />7 <br />48-02.031 <br />1/2310 <br />133 CamScanner