Laserfiche WebLink
Day Ph _ 99-4 ' 93c•95S-Night Ph CONTACT PERSON ANI(/ MO( tiPtt41 <br />PROGRAM ELEMENT 1681 FEE $237 <br />INSPECTOR!! 9828 PERMIT VALID /0 31 <br />0 Check # V / 67)/4-- AMOUNT PAM <br />0 Cash REVIEWED BY <br />48-02-034 <br />1/23/13 <br />SR0087313 4ir / -77 1C13tV,21, 23 <br />2- <br />I. <br />SLIFC110/90 FIEE <br />to /0/o// <br />Date <br />ACCOUNTING OFFICE <br />i) ASTERFILE RECORD IN <br />0 Other FEE <br />0 Food Handler <br />VOICE # 5 37 <br />Date / <br />ORRIATION PINK <br />0 Ag/Cannery Waste Site <br />0 Process/Recycle Facility <br />0 Dumpsters > 20 Cu yd (a of Units) <br />0 Sludge/Ash Site <br />0 CIA Landfill Site <br />0 Farm/Ranch Cleanup Site <br />I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Pro ram at Existin • Factlit ONew EH Pr ram and New Facilit <br />Faculty ID Pro ram Record ID 5 <br />Facility Address 110 N EL DORADO <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 Food Handlers Course required: YES 0 No 0 <br />0 Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />ID Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />0 Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # <br /> <br />Sticker !! <br />0 Mobile Food Prep Unit— Make Vehicle Type <br />Registration # Sticker License # <br />Color <br /> <br /># <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 />0 Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit <br />CUPA <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 />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 MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />0 Abandoned NW Site 0 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 />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 />ID Pumper VehIcteRogiStratiOrtlJ <br />0 Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />0 Landfill 0 Transfer Station <br />0 Waste Tire Facility 0 Compost Facility <br />0 Refuse Vehicles (5 or units) <br />MEDICAL WASTE PROGRAM (4500) <br />0 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 <br />0 Common Storage Facility 0 2 - 10 0 Transfer Station 0 Veterinary Clinic <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Fonn <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />0 Kennel <br /> License # <br />0 Package Treatment Plant <br /> <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br /> <br />Small Generator 0 Limited Hauler <br />0 11 - 60 0 > 60 generators <br />,r-; 3S. • $G.5 •