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PROGRAM ELEMENT / FEE <br />INSPECTOR # <br /> <br />PERMIT VALID <br />Check # AMOUNT PAID <br />Cash REVIEWED BY <br />48-02-034 <br />1/23/13 <br />Z71-2 5: 00 CI Surchar e FE <br /> <br />.2- to 2- <br /> <br />2 ,C.00 Date <br />ACCOUNTING OFFICE <br />CI Other FEE <br />CI Food Handler <br />INVOICE# 5 <br />Date 24 2— <br />MASTERFILE RECO D INF RMATION PINK <br />176gbgyo <br />New EH Pro ram at Existing Facilit New EH Pro ram and New Facilit <br />PAYMENT <br />RECEIVED <br />FEB 2 2 2024 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility ID f -ADD2.E62-72.. Program Record ID Pk0Sql/012" <br />Facility Address 4°&•3 3 ,Z3( ,S1/2)(3e4li <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating CapacitY77"7 Square Footage <br />Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # <br />CI Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />DAIRY PROGRAM (2000) <br />0 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 />El 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 />CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />CI Other CUPA Program <br />HOUSING PROGRAM (2400) <br />CI 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 />CI Environmental Assessment 0 UST-CAP Site CI Local HW Cleanup Site 0 NPL/SEP Cleanup Site CI UIC Site <br />CI Abandoned HW Site El 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 CI Pool <br />VECTOR CONTROL PROGRAM (4000) <br />CI Poultry Farm Maximum number of birds <br />CI Spa CI Out of Service Pool/Spa CI Natural Bathing Area <br />CI Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # <br />CI Pumper Yard :I Package Treatment Plant CI Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill CI Transfer Station 0 Ag/Cannery Waste Site <br />CI Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />CI Refuse Vehicles of Units) CI Dumpsters > 20 cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care CI Acute Care CI Skilled Nursing 0 Large Generator <br />CI Transfer Station CI Veterinary Clinic 0 Common Storage Facility CI 2 - 10 CI 11 -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 / C4-1 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />q.çDEPARTMEN7 <br />Food Handlers Course required: YES kr No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />0 Special Event---Dates of operation from to 0 CFO CI A 0 B <br />Capacity Vehicle # <br />Sludge/Ash Site <br />CI CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />0 Small Generator CI Limited Hauler <br />0 > 60 generators <br />e / Day Ph _e_57_)__9_44 54iftlaS--