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PERMIT VALID <br />AMOUNT PAID <br />PROGRAM ELEMENT b S FEE 237 •- o Surch 0 Other FEE <br />INSPECTOR # <br />Check # <br />Cash <br />48-02-034 <br />1/23/13 <br />to <br />Date <br />REVIEWED BY ACCOUNTING OFFICE <br />Food Handler <br />INvoicE# 3c7/73/ <br />Date 27 Pi-- <br />MASTERFILE RECORD I FORMATION PINK <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 />Facility ID -FA W2gb.17 <br />Facility Address "\ ?DC) < \ çiI (N_Ac--\ sf <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No LI <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 />pa Mobile Food Vehicle --Make 'FL) R9 Vehicle Type 11.,) Color <br />Registration # License # k1)p/ i>1 Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # 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 />o 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 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 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) PAYMENT <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Sin <br />rt <br />gFt06,1,‘ <br />FEB <br />0 Body Art Facility-Sterilization (4121) 0 Body A Temp Event Co-ord (4130) 0 Body Art-Temp EventENMvi <br />COUNTY <br />SOLID WASTE PROGRAM (4400) <br />afie.FAallY(4131) <br />LIQUID WASTE PROGRAM (4200) E 2 Pumper VehicleRegistration # License # Capacity <br />0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number ofS6N49.3 <br />HEA <br />RoNmENTAc <br />VeLFT:ilcplep#papt. TumuT <br />Landfill 0 Transfer Station Ag/Cannery Waste Site Sludge/Aih <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (4 of Units) LI 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 />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />0 CONTACT PERSON c tutiao,r Day PhX )•^9',,) --1,9:7Night Ph <br />Program Record ID FPLE/P26:1(:) <br />do-V