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FEE 4't 3 Surcharg <br /> <br />PERMIT VALID 121'4 2_3 to <br />AMOUNT PAID S76. 06 Date I <br />PROGRAM ELEMENT <br />INSPECTOR # <br />CI Check # <br />Cash REVIEWED BY g_ F ACCOUNTING OFFICE <br />atc (72O g/ <br />CI Other FEE <br />0 Food Handler <br />INVOICE # 39')21.,1.— <br />.3 Date / 2— <br />MASTERFILE RECORD I FO <br />le <br />RMATION PINK 48-02-034 <br />1/23/13 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility ONew EH Program and New Facility <br />Facility ID FA o --/ <br /> <br />Program Record ID Pk,o5-4—gg <br />Facility Address 1960 McHenry Ave, Escalon, CA 95320 <br />(Please check the appropriate description <br />FOOD PROGRAM (1600) <br />24 Restaurant: Seating Capacity 55 <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br />Sticker # <br />Color <br />Sticker # <br />to 0 Ice Plant 0 Produce Stand <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 El NPL/SEP Cleanup Site CI UIC Site <br />CI 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 0 Pool <br /> <br />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 /> 0 Kennel <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 # Capacity Vehicle # <br />Pumper Yard <br /> 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station El Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (# of Units) <br /> CI Dumpsters > 90 cu yd (# of Units) <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 0 Common Storage Facility 0 2 - 10 <br /> <br />CI 11 - 60 0 >60 generators <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 Daley Matadamas Day Ph 209-652-8931 Night Ph 209-652-8931 <br />Registration # <br />Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />Square Footage Aprox 2000 <br />0 with Food Preparation <br />w/Meat Market only <br />Vehicle Type <br />License # <br />and specify size, number of units and pertinent information.) <br />Food Handlers Course required: YES <br />El Vending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />PA YMENT RE CE/VED <br />DEC 0 4 2023 <br />SAN JOAQU/N COUNTY ENVIRON MENTA L HEALTH <br />DEPARTM <br />NO <br />0 Chemical Toilets ----Number of Units <br />CI Sludge/Ash Site <br />CI CIA Landfill Site <br />0 Farm/Ranch Cleanup Site