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3 0 Surchorge/EE <br />th /2--( 3 / )4? <br /> Date 27 .242 Z, <br />o Cash <br />48-02-034 <br />1/23/13 <br />ACCOUNTING OFFICE <br />PROGRAM ELEMENT I //3 FEE <br />INSPECTOR # PERMIT VALID <br />Check # AMOUNT PAID <br />REVIEWED BY <br />El Other FEE <br />ID Food Handler <br />INVOICE # 733 <br />Date ;1 72 <br />MASTERFILE RECORD NFORMATION PINK <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility kNew EH Program and New Facility <br />Facility ID F-A002, 077 Program Record ID v F-39-7 -7 (0 <br /> <br />Facility Address i-/-40 S.- fii r 04- 14y , siTc-e-riti q._f2.01.47 <br />(Please check the appropriate description and specify size, number of uniis 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 />0, Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br /> <br />AMobile Food Vehicle --Make Vehicle Type Color <br /> <br />Registration # , -, 6.77,c7 fr License # 1f37/:13 Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br /> <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 <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 />LI 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 />ID Hotel/Motel Number of Units ID 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 <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />0 Out of Service Pool/Spa PAYMfiteirthing Area <br />RECEIVED U Kennel <br />FEB Z 6 2024 <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facilit -Sin le Use ( ) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Te rat acility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License If <br />Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br /> <br />HEALTH DEPARTMENT <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br /> <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 (# of Units) 0 Dumpsters >20 cu yd (# 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 />CONTACT PERSON !1c Z_ Day Ph(7 (--'2?1-371 o; Night Ph