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REVIEWED BY <br />. 01844 <br />ACCOUNTING OFFICE <br />PROGRAM ELEMENT i 3 FEE 2 4. Surchar <br />PERMIT VALID 1 I .23 to 12-3/ 2, <br />AMOUNT PAID It) Date 1 <br />iNSPECTOR # s çcy <br />ID Check # <br />e F 0 Other FEE <br />MASTERFILE RECORD INFORMATION PINK 48-02-034 <br />1/2 3/13 <br />0 Food Handler <br />INVOICE # <br />Date 1VZ .z3 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />1:5kNew EH Program at Existing Facility <br /> ElNew EH Program and New Facility <br />Facility ID riq A s-93 Program Record ID P12/35-97X773 <br />Facility Address /7/7 11)9 ccf.. 577C-k_ /71tv (_-fi c7f2_0 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />El Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />El Mobile Food Vehicle --Make Vehicle Type 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 />0 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 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 /> <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 />El Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (# of Units) <br /> <br />Sludge/As1414014".. <br />CIA Landikeipip..."ICA47 <br />Farm/Ranch-Mat <br /> <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form rii pep EiV7k 7)' <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 mperators <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM Mr <br />0 Small Generato Limited flakkoos <br />IYEAL ROkt7 COUN <br />NOV n <br />,40 <br />Day Ph ' . . e r , ---> (-- Night Ph N , <br />Registration # License # y b>a, / 7 a73 <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />SOLID WASTE PROGRAM (4400) <br />Landfill <br /> <br />O Transfer Station <br />Waste Tire Facility O Compost Facility <br />Refuse Vehicles (# or units) <br />MEDICAL WASTE PROGRAM (4500) <br />CONTACT PERSON ;