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Other FEE 0 Surcharge FEE <br />to 12- 2L/ <br />Date Ste, <br />El Food Handler <br />INVOICE # 3 <br />Date <br />PROGRAMELEMENT7k 7 FEE <br />INSPECTOR # LB PERMIT VALID <br />Check #. AMOUNT PAID <br />lE'ch \11614 REVIEWED BY ACCOUNTING OFFICE .2- <br />MASTERFILE RECORD INFORMATION PINK 48-02-034 <br />t As 1/23/13 <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 rilOID 2-a-CO7 Program Record ID ?ROS-1-1-g5-67 1 <br />Facility Address (3p u3 6raytb I ek.ne. 411 4 <br />(Please check the appropriate description and specify size, number of units an pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Conic. <br />if1fo <br />Square Footage Food Handlers Course required: YES 0 No 0 <br />0 with Food Preparation OVending Machines Number of Units <br />0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Vehicle Type 4-1F Color z...Aeir <br />License # rA Sticker # I p3 o' <br />Vehicle Type Color <br />Registration # <br /> <br />License # Sticker # <br /> <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br /> <br />Special Event---Dates of operation from <br /> <br />to 0 CFO 0 A 0 B <br /> <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 Housinq/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 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 />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 VehicleRegistration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />0 Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles Itt of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 <br />EA/if W PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form NEAL oN A/ C <br />OUN <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM 4Z/Vr DEpAi.b , <br />Day Ph 14,o8 --e6 0 -lccl Night Ph ihog-130 —1110 CONTACT PERSON 5 k g 4,A) 14 0-734 <br />0 Kennel <br /> License # <br />0 Package Treatment Plant <br /> <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br /> <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (# of units) <br />Sludge/Ash <br />CIA Landfil itbr <br />Farm/Ran <br />Small Generator 0 LIM& 01511e5ro, <br />11 - 60 filAy 60 aenerat6W4