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Food Handler <br />INVOICE # <br />Date 3 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />fiNew EH Program at Existing Facility 0 New EH Proglam and New Facility <br /> <br />Facility ID TA(Y)2._S-11 I Program Record ID Ple-05 2-1-q0b1 , <br />Facility Address SI'S- -- - C-1 __,,._'. NcA 6-/-42 . (---c_i\ <br />(Please check the appropriate description and specify size, number of 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 I:Wending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Ttt Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # 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 <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 />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-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) <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 <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (# of Units) 0 Dumpsters > 20 cu yd (it of units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 11 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERG N Y NOTIFICATION FOR THIS FAC LITY 0/OR PROGRAM <br />CONTACT PERSON 141 'My-- 1, Day Ph 317 '9)7)7-2 Night Ph (40 4 ) T72 - <br />—8-44en, <br />0 Sludge/Ash Sue <br />o 0 CIA Landfill R , , <br />0 F a rm/Ra re4AICE.Aluk,01/e4aQnt ju, 4 i tf024 <br />0 Large Generator 0 Small Generator 0 ti4t4.4 <br />ri 8.2,...27k. <br />Con <br />0 > 60 generatturpitiEwr - 60 <br />0 Chemical Toilets ----Number of Units <br />Capacity Vehicle # <br />I' r4 <br />PROGRAM ELEMENT kb.S5 FEE 2 <br />INSPECTOR # PERMIT VALID 5.1,3. 2'-j <br />Check # AMOUNT PAID ,* g. <br />12/c <br />REVIEWED BY <br />0 Surcharge FEE <br />to k 2 S k • 2 <br />Date <br />Other FEE <br />S1-11° <br />ACCOUNTING OFFICE <br />48-02-034 <br />1/23/13 C 11-13281:)21 <br />MASTERFILE RECORD I FORMATION PINK