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1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />11- New EH Prcyram at Existing Fee° <br />Neil ID 44,0C) <br />ONew EH Pro ram and N Facil <br />I <br />.. . Pro ram Record ID <br />ee LA 0' .e0 I Irt A is S' C \ t Sn <br />PAYMEW T IS'ECIL/$1) <br />NO <br />V <br />V 08 2023 <br />SAN JOA QU/N COUNTY /R ONMEN <br />TA L <br />HE-4 <br />EPA R TMENT <br />Facility Address • <br />IF:3 <br />Restaurant. Seating Capacity Square Footage Food Handlers Course r t_e_gilims_1: <br />(PolOaos:Reho7kAttAheetToPor)°P6'te <br />deecrIption and specify size nu er of units and pertinent Information.) <br />DO Ceomiml m.met_s,iar IssaryODuiyse otofrartagoenly 0 with Food Preparation <br />YES Vi... No 0 <br />OVending Machines Number of Units <br />Rt. <br />_ <br />0 Mobile Food Vehicle -Make <br /> 0 re/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Registration # <br /> Vehicle Type Color <br />0 Mobile Food Prep Unit- Make <br /> Licen.# Sticker* <br /> <br />r <br />Registration # <br />Vehicle Type Colo <br /> <br />Sticker If <br />0 Temporary Food Facility -Dates of operation from <br />License # <br />to 0 Ice Plant 0 Produce Stand <br />0 Special Event—Dales of operation from <br />DAIRY PROGRAM (2000) <br />0 Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />0 Hazardous Materials Business Plan (1900) Number of chemicals - <br />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 Housmq/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local NW Cleanup Site 0 NPUSEP Cleanup Site 0 UIC Site <br />0 Abandoned HW Site 0 non-NPUSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remedlation 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 />0 Poultry Farm—Maximum number of birds 0 Kennel <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 />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 />0 Pumper Vehicle Registration # License #Capactty Vehicle # <br />0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ---Number of Units <br />SOLID WASTE PROGRAM (4400) <br />0 Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site <br />0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />0 Refuse Vehicles (#01 Units) 0 Dumpsters > 20 cu yd (#01 units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />0 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />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 46-02-003 Blue Application Form <br />EMERGENCY N TIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph 90. VA- t•MAITlight PThitl <br />PROGRAM ELEMENT 1608 FEE 186 0 Surcharge FEE 0 Other FEE <br />INSPECTOR # 4589 PERMIT VALID IViLaTO it( 02- 0 Food Handler <br />0 Check # 0-542---- AMOUNT PAID g 00 Date INvoicE# 3;70 G• <br />ACCOUNTING OFFICE Date /0 '/2_3 <br />MASTERF ILL RECORD 1 FORMATION PM <br />17 /73 /gqS <br />to 0 CFO 0 Al:IB <br />13 Cash <br />41-02-034 <br />1/23/13 <br />REVIEWED BY