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FEE $2-5(} 0 Surch 0 Other FEE T (o35 <br />PERMIT VALID II 1/ <br />/ <br />to 0 Food Handler <br />AMOUNT PAID ...-- Date 12- INvoicE # CJ S <br />Date / 3 <br />PROGRAM EL <br />INSPECTOR # <br />Check # <br />Cash REVIEWED BY <br /> <br />ACCOUNTING OFFICE <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility <br />Facility ID rA 002_71 7 -7., <br />ONew EH Program and New Facility <br />Program Record ID Wo54-1--8.5 2-4 <br /> <br />Facility Address „Iva //rta-1-41 <br />(Please check the appropriate description and specify <br />FOOD PROGRAM (1600) <br />Istaurant: Seating Capacity <br />PP-Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make CA4W,111( <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 to <br />hief-se- `50x-1Mi 19 <br />size, number number of units and pertinent information.) <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 />Square Footage <br />[D.Sith Food Preparation <br />0 w/Meat Market only <br />Vehicle Type <br />License <br />Vehicle Type <br />License # <br />to <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 />El 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 />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 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 <br /> 0 Out of Service Pool/Spa <br />VECTOR CONTROL PROGRAM (4000) <br />0 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) O Body Art Facilit <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) O Body Art-Temp <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # <br />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 <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (# of Units) 0 Dumpsters > 20 cu yd (# of 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 />Transfer Station 0 Veterinary Clinic <br /> 0 Common Storage Facility 0 2 - 10 0 11 - 60 <br /> 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACI AND/OR PROGRAM <br />CONTACT PERSON (9eV-e- i it/ Cry Day Ph 951-,2049- Night Ph 7/ 9 -7-021 9- <br /> <br />48-02-034 <br />1/23/13 <br />MASTERFILE RECORD INFORMATION PINK <br />0.114SAITAre a <br />CEIVED <br />°e nt' 1 2023 <br />atiftity (4131) <br />ARTMENT <br />Capacity Vehicle # <br />4,811.1•„•-.1*.l. •