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FORMATION PINK MASTERFILE RECORD I <br />Surch ge F E 0 Other FEE <br />to I S( 1:1 Food Handler <br />Date (3/Z7 INVOICE# 3 <br />( Date 3 2 2 <br />103 <br />ACCOUNTING OFFICE <br />PROGRAM ELEMENT <br />INSPECTOR # <br />El Check # <br />Cash <br />48-02-034 <br />1/23/13 <br />FEE <br />PERMIT VALID <br />AMOUNT PAID <br />REVIEWED BY (4 --e <br />I 7 g T--5 LtP <br />Ag/Cannery Waste Site <br />CI Process/Recycle Facility <br />Dumpsters > 20 CU yd (tt of Units) <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility <br />SithletivJO.A_QuiN couNry <br />HEALTLIPNMENTAL <br />LjEpAR !MEW <br />Food Handlers Course required: YES 0 No 0 <br />:Wending Machines Number of Units <br />qe, <br />Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />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 />El CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />El Hazardous Waste Generator (2200) >- Tons Generated Per Year <br />CI Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) El PBR HHW (2236) <br />CI 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 />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 CI UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />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 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) CI Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care :I Skilled Nursing CI Large Generator CI 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 />T_AERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON 6 1616 akil Day Ph -/tri B4-(d.si3 Night Ph <br />Facility Address -Th'e S'OAlli/bilkta &V <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />El Restaurant: Seating Capacity Square Footage <br />0 Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only 0_11,ultiple Departments 0 Prepacka ed Goods Only <br />jfa Mobile Food Vehicle --Make 3tr\-1-t Vehicle Type Van , <br />Registration # License # LUi32-S <br />Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />Facility ID rADD25c72-4 Program Record ID ?k/D541/7)17 <br />ONew EH Program and New Facility <br />to <br />Color <br />Sticker # <br />Color <br />MAR <br />CEivED <br /> 29 <br />PAYmENT <br />2024