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0 New EH Pro ram at Existin. Facillt <br />q-‘t Faculty ID <br />Dfdraw Pm ram and New Facilit <br />Program Record ID <br />O <br />0 Surch <br />to 10 <br />Date <br />FEE <br />. PERMIT VALID <br />t ', <br />AMOUNT PAID <br />REVIEWED BY ACCOUNTING OFFICE <br />PROGRAM ELEMENT <br />INSPECTOR /f <br />Ci Check ti <br />Ei Cash <br />48-02-034 <br />1/23/13 <br />0 Other FEE <br />0 Food Handler <br />INyacE# 3 6:10 ° 5 <br />ate 0- ta IJAL 3 <br />TERFILE RECORD INFO ATION PINK <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility Address c2 1 (07 Sr.srlcirc'v ST--1 AileAeCc'• x CA- 1 c1S 3 3 (0 <br />(Please check the appropriate description and specify size number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />El pestaurant: Seating Capacity iare Footage Food Handlers Course required: YES 0 No 0 <br />L. _ Commissary 0 Dry storage only f , with Food Preparation OVending MachinesNumber of Units 0 Retail Market----Square footage Q w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />0 Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />0 Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration It License # Sticker // <br />0 Temporary Food Facility --Dates of operation from t0 0 Icy Plant 0 Produce Stand <br />0 Special Event---Dates of operation from to ifri/CF0 g A 0 B <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 />0 Hazardous Materials Business Plan (1900) Number of chemicals: <br />CaIARP 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 Et forms <br />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Q Hotel/Motel ----Number of Units 0 Jail or Exempt Institution ----Number of Units 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 NPUSEP Cleanup Site 0 WC Site 0 Abandoned HW 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 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 />0 Body Art Facility-Sterilization (4121) 1:1 Body Art Temp Event Co-ord (4130) ID Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicieRegistration # License #Capacity Vehicle # <br />0 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 0 Sludge/Ash Site 0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />0 Refuse Vehicles pot units) 0 Dumpsters > 20 cu yd (nor units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large 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 EHD 46-02403 Blue Application Fenn <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON RoNni; ro R e y s --j:._._ Day Ph _7-L/44,3 Night Ph 001-LN7- VI/0