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FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity Square Footage <br />0 Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />0 Mobile Food Vehicle --Make <br />Registration # <br />CI Mobile Food Prep Unit-- Make <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Vehicle Type Color <br />License # Sticker # <br />Vehicle Type Color <br />License # Sticker # <br />to CI Ice Plant 0 Produce Stand <br /> to }41 CFO A B <br />Food Handlers Course required: YES 0 No 0 <br />1:1 Cash <br />48-02-034 <br />1/23/13 caf <br />REVIEWED BY <br />Food Handler <br />INVOICE # <br />Date <br />PROGRAM ELEMENT 162 CIE FEE <br />INSPECTOR # 1C. PERMIT VALID to <br />CD Date <br />ACCOUNTING OFFICE <br />CI Other FEE <br />Check # AMOUNT PAID <br />MASTERFILE RE ORD INFORMATION PINK <br />(760 1 'Ict`f2_, <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />"0 New EH Pro9ram at Existing Facility El New EH Program and New Facility <br />Facility ID rA 6 o73 Program Record ID <br />Facility Address Address 2l/A- Utric Writi C,6 <br />(Please check the appropriate description and specify size/number of units and pertinent information.) <br />FEB r <br />sk4v o 2024 <br />4C)CliNC NE,AN4l .A1Cr)UNr), <br />DEP,410.44/ivr <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 />El 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) 1:1 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 NPUSEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPUSEP 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 CI 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) CI Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # <br />0 Pumper Yard 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 (It of units) El Dumpsters > 20 cu yd of units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing El Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic CI Common Storage Facility 0 2 - 10 <br /> <br />O 11 - 60 0 >60 generators <br />CONTACT PERSON - <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br /> ) , EMERGENCY NOTIF7101L(4 FOR THIS FACILITY AN /OR PROG AM <br /> <br />vix,y /frt. Day Ph <br /> Night Ph <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />El Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site