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Other FEE <br />Food Handler <br />INVOICE # I <br />Date 2_ <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility ONew EH Program and New Facility - <br />-9L, Facility ID Fi co zzoss-s- <br />0 Facility Address C9"V:. S c erctrvNen ft <br />(Please <br />- <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 0Vending 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 # License # Sticker # <br />'Mobile Food Prep Unit-- Make Mcit>o .T-r-At c r----, Vehicle Type --rre't t 1 e. r Color kA) 14 ( I-- e_._ <br />Registration # License # 11 v j< 2 '3 4., -2-- 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 />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <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 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 11911Plogi. <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) RECpnit„. <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Singie•vit4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-TempitittntIMpbile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) `1 20: <br />Pumper VehicleRegistration # License # Capacity SAN JaAcittiehicie # <br />CNy2aGAZ.t-OU/N; 0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Ntiffilk <br /> <br />DcrogrAL <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (4 of Units) 0 Dumpsters > 20 CU yd (4 of Units) 0 Farm/Ranch Cleanup Site <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 Form <br />A ,(6. - <br /> <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />1.D CONTACT PERSON J'a) <br /> <br />\\Y Day-\--4 ` Ph 2O9- 1.- 10 '6101U Night Ph <br />Program Record ID WO5 '737 <br />ARTMEN <br />PROGRAM ELEMENT 6, 35- FEE ,`..? Surch F <br />INSPECTOR # PERMIT VALID c211 / to <br />Check # V / 5 4 AMOUNT PAID 0 -- Date /2.---10Aliff <br />Cash REVIEWED BY ACCOUNTING OFFIC $ (10 <br />48-02-034 <br />1/23/13 <br />MASTERFILE REC RD I FOR AT1ON PINK