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PROGRAM ELEMENT 1681 FEE <br />INSPECTOR # 9828 PERMIT VALID <br />Check # 00 i7 AMOUNT PAID <br />REVIEW ED BY <br />o Surcha <br />to <br />Date <br />ACCOUNTING OFFICE-- <br />El Other FEE <br />0 Food Handler <br />INVOICE # 2...P3 4. <br />Date 317/1 <br />MASTERFILE RECORD I FORMATION PINK <br />getF <br />E2 <br />$2 00 <br />LI Cash <br />48-02-034 <br />1/23/13 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility ElNew EH Program and New Facility <br />Facility ID no„..2._...23-1 Program Record ID <br /> <br />Facility Address 2029 E HARDING WAY <br />specify size, number of units and pertinent information.) (Please check the appropriate description and <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity <br />IN Commissary 0 Dry storage only <br />Retail Market----Square footage <br /> <br />El Mobile Food Vehicle --Make <br /> <br />Registration # <br />Mobile Food Prep Unit-- Make Vehicle Type <br /> <br />Registration # License # <br />Temporary Food Facility --Dates of operation from to <br />Special Event---Dates of operation from <br />Square Footage <br />with Food Preparation <br />0 w/Meat Market only <br />Vehicle Type <br />License # Sticker # <br /> Color <br />Sticker # <br />0 Ice Plant 0 Produce Stand <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />to El CFO 0A0B <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 />El Environmental Assessment 0 UST-CAP Site CI Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned H W 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 El Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <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 VehicleRegistration # License # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <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 <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 0 > 60 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />MERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON 0 Day Ph 7,61- 1 0- 0 qg Night Ph <br />0 Kennel <br />Capacity Vehicle <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (# of Units) <br />Sludge sh Site • Trci) <br />CIA Lan Sit <br />El F a C I a e <br />043i1Q(//4, col./ •