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0 Surcharg FE <br />2-3 to 12- 3( —- 0 Food Handler <br />Date 1 2.3 INVOICE # <br />1E)- Date / 23 <br />0 Other FEE <br />ACCOUNTING OFFICE <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility ONew EH Program and New Facility <br />Facility ID 60)-702— Program Record ID 'REG <br />G 2- LA D <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square <br />Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />,tc Mobile Food Vehicle --Make Vehicle Type <br />0 Ice Plant 0 Produce Stand <br />0 CFO 0 A 0 B <br />Facility Address 3 56 Ci11A Ave,Load OA <br />Footage <br />PA <br />IV <br />ha <br />-"ENT <br />Lzo oEc Op <br />SAN., u 2023 <br />littTitoka. OuAlry <br />Food Handlers Course required: YES 0 VS 0 <br />:Wending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Registration # License // Ri q 00111 <br />Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />Temporary Food Facility --Dates of operation from to <br />Special Event---Dates of operation from to <br />Sticker # <br />Color <br />Sticker # <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) 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 <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 />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # <br />Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (# of Units) 0 Dumpsters > 20 cu yd (#0/ Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator <br />Transfer Station 0 Veterinary Clinic 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 ANVOR PROGRAM <br />CONTACT PERSON 10 -N el v-ti/x_ Day Ph :200 )2-1 70L-1(4; Night Ph //09 • _;2„ 7 7---o1i ce <br />0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />0 Kennel <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />Small Generator 0 Limited Hauler <br />0 > 60 generators <br />PROGRAM ELEMENT 0 , FEE <br />INSPECTOR # 1 g >,‹ PERMIT VALID <br />Check # 0 if Amo NT p D <br />Cash REVIEWED BY <br />MASTERFILE RECORD FORMATION PINK <br />2 48-02-034 <br />1/23/13