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r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />— ca. .. rsiaccsa=lexArtaaarccac . <br />0 Other FEE <br />1:1 Food Handler <br />ACCOUNTING OFFICE <br />0 Surch <br />to <br />Date INVOICE <br />Date <br />48-02-034 c <br />1/23/13 <br />PROGRAM ELEMENT 1681 FEE $237.00 <br />44 INSPECTOR ft 9828 PERMIT VALID <br />51'1 AMOUNT PAID <br />Cash REVIEWED BY <br />Thfte OLC /4 11 /0014 MATILE RECORD INFORM TION INK <br />r-*/ <br />Square Footage <br />with Food Preparation <br />w/Meat Market only <br />Vehicle Type <br />License # <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br /> Color <br />Sticker # <br />0 New EH Program, .at E.xistiafa,9ilqx New EH Program and New Facility <br />Facility ID Program Recor—d—Ilf: <br />Facility Address 110 N Fl DORADO ST <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity <br />IN Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br />Registration # <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 CI 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 I 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 />0 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 />0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPLISEP Cleanup Site 0 UIC Site <br />0 Abandoned HW Site 0 non-NPUSEP 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 # Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />PAYMizikob. <br />Ag/Cannery Waste Site 0 Sludge/Aittfloir. <br />Process/Recycle Facility 0 CIA Landfillg't6C11/ e <br /> <br />0 Dumpsters > 20 cu yd (/f of units) 0 Farm/RaWIfanup Sip <br />1 2 2024 <br />0 Skilled Nursing 0 Large Generator 0 Small Generator <br />O Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 -60 ii fay <br />rl'W;AWr.,k.' PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form ""mEfir <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM , Day Ph ') , ' i- ::,1 %'''' Night Ph'--', (1 <br />Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />0 Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care <br />CONTACT PERSON