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PROGRAM ELEMENT / (42 / FEE <br />INSPECTOR # t>/(S1 ) PERMIT VALID <br />Check # Vi (--- AMOUNT PAID <br />CI Cash REVIEWED BY <br />0 Surchatrig 0 Other FEE <br /> to El Food Handler <br />Date I IN INVOICE # 3 <br />Date // ACCOUNTING OFFICE <br />yto A <br />Facility ID OD-27 141"D Program Record ID <br />El New EH Program at Existing Facility New EH Program and New Facilit SAN Jo .Quitv co t: y <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />t <br />P2osti- <br /> z u` <br />NOv 1 4 202 , <br />Facility Address V 7 -,)) (1/ 1 / r /--)/r CITY11077‘1 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />El Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />El Retail Market----Square footage <br />CI Mobile Food Vehicle --Make <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # Sticker # <br />Temporary Food Facility --Dates of operation from to CI Ice Plant CI Produce Stand <br />Special Event---Dates of operation from to CI CFO 0 A 0 B <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 />CI Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />CI Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) CI CE (2233, 2234, 2235, 2237) 0 PBR (2231) CI PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />CI Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units CI 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 El 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 CI Pool 0 Spa CI Out of Service Pool/Spa El Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />CI Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />1:1 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 />CI Pumper VehicleRegistration # License # <br />Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (#0f units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care El Skilled Nursing 0 Large Generator <br />CI 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 AND/OR PROGRAM <br />CONTACT PERSON <br /> Daniel Amspaugh Day Ph 310-730-5440 Night Ph 310-730-5440 <br />Square Footage Z._ SC <br />0 with Food Preparation <br /> <br /> 0 w/Meat Market only <br />Vehicle Type <br />License # Sticker # <br /> <br />Vehicle Type Color <br />License # <br />0 Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />0 Kennel <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (8 of units) <br />CI Sludge/Ash Site <br />0 CIA Landfill Site <br />CI Farm/Ranch Cleanup Site <br />0 Small Generator CI Limited Hauler <br />El > 60 generators <br />48-02-034 <br />1/23/13 C.6)-1 1719g-8504 <br />MASTERFILE RE ORD FORMATION PINK