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0 Surcharge FEE <br />to t 3/ <br />Date <br />1C.00R FEE <br />PERMIT VALID <br />AMOUNT PAID Le, <br />REVIEWED BY ACCOUNTING OFFICE <br />PROGRAM ELEMENT <br />INSPECTOR # <br />Check # <br />Cash <br />48-02-034 <br />1/23/13 <br />0 Other FEE <br />0 c?- 0 Food Handler <br />INvOICE # 3 7 1U-- <br />Date y <br />STERFIL RECOR INFORMATION PINK <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />1 52- 1 9 <br />License # Sticker # <br />Color <br />Sticker # <br />0 UIC Site <br />Site <br />0 Natural Bathing Area <br />0 Chemical Toilets ----Number of <br />JArit!le232-4--_ <br />Ag/Cannery Waste Site <br />SAN JOAQUIN COUNTY <br />NVIRONMENTAL <br />Process/Recycle Facility 0 CIA Landfill Site <br />Dumpsters > 20 cu yd (// of Units) 0 Farm/Ranch Cleanup Site <br />New EH Program at Existinacility 0 New EH Program and New Facility <br />Facility ID rii-ILT-27 u3 Program Record ID PG 51/ D <br />Facility Address85 31 AfT 12— csToo <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />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 />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # <br />Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />Temporary Food Facility --Dates of operation from to / 0 150 Plant 0 Produce Stand <br />Special Event---Dates of operation from to a CFO AA 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 />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 <br />Abandoned HW Site 0 non-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art F a ci lityRAMIENT20 ) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp RECENEDility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License #Capacity <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 (# 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 0 11 -60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Fort <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM 4 CONTACT PERSON 16 12-1 -1-Asi FsAf24,-/ T Day Ph 261 — 40L951INight Ph