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Surch <br />9 (-X _s PERMIT VALID 2- 2,2D /22? to <br />V Li--2)C1-- AMOUNT PAID A <br />REVIEWED <br />- <br />REVIEWED BY ACCOUNTING OFFICE filai <br />41140 01 1-2 <br />INSPECTOR # <br />Check # <br />Cash <br />PROGRAM ELEMENT I FEE 2- <br />Food Handler <br />INVOICE # 3 "732— <br />Date 7 2-- <br />Other FEE <br />48-02-034 <br />1/23/13 <br />MASTERFILE RECORD INFORMATION PINK <br />'SAN jOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION/F„ORM <br />New EH Program at Existing Facility O'New EH Program and New Facility <br />Facility Address -. . 7. 3 o <br />(Please check the appropriate description and specify size, number oi 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 /> <br />0 Mobile Food Vehicle --Make Vehicle Type Color <br /> <br />Registration # License # Sticker # <br />Of Mobile Food Prep Unit-- Make 6 AA L Vehicle Type 31 I I- Color p i 0 (...._ <br /> <br />Registration # License # -l!C ( 0 (-1 193 Sticker # IA) iqi ILI 75-- <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 <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 />El 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-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) " f <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Re& Bat,17,MArea <br />SAN JOA1 'fLJNIY 0 Body Art Facility-SeglaFUse (4126li <br />0 Body Art-Temp El4Rit•Tikbile Facifit4/(4131) <br />MEDICAL WASTE PROGRAM (4500) Dpa.WAITAL <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Gentrator 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 />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph Night Ph <br />Facility ID F_AD2...gb-7g Program Record ID 05-ii-vc.,1 <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds EFIRpn I <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <br />License # <br />0 Package Treatment Plant et" vdto <br />FE d 0 Ag/Cannery Waste Site 4 3 "n2E Sludge/Ash Site <br />0 Process/Recycle FaciAtig jcr CIA Landfill Site <br />0 Dumpsters > 20 cu yd go%tKiftaIN cow; Farm/Ranch Cleanup Site <br /> Capaci <br />0 Chemical To <br />Vehicle # <br />f Units <br />CONTACT PERSON