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Other FEE <br />Food Handler <br />INVOICE # 3 <br />Date 25 2-- <br />PERMIT VALID <br /> AMOUNT PAID <br />REVIEWED BY <br />Date <br />ACCOUNTING OFFICE <br />PROGRAM ELEMENT 1( Cg FEE <br />INSPECTOR # <br />Check # <br />CI Cash <br />Surchar e FEE <br />to 3 3/ <br />0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />0 Kennel <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 Cu yd (4 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 ONew EH Program and New Facility <br />Facility ID •V;44)0 2-2-1 2-4- <br /> <br />Program Record ID ?g_co-ii=to <br /> <br />Lti. LoA; CA <br />size, number of units and pertinent information.) <br />Mobile Food Prep Unit-- Make <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />JOPAAQ:7 <br />SAN <br />7 <br />ip7AER c27 272,,' <br />Eivvino ...coutv7‘,. <br />HEAL:171h himENTAL <br />Facility Address(..)0 tj. Flani <br />(Please check the appropriate description and specify <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br />Registration # <br /> Square Footage <br />0 with Food Preparation <br />w/Meat Market only <br /> Vehicle Type <br /> License # <br /> <br /> Vehicle Type <br />License # <br />to <br />to <br />WAIT <br />Food Handlers Course required: YES 0 No 0 <br />:Wending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />Sticker # <br />li <br />0 Ice Plant 0 Produce Stand <br />CF0 IS6 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 <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <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 <br /> <br />0 Package Treatment Plant <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 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 /> <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON it5cRk &1e\. Day Day Ph -101 -175. -Sit', Night Ph <br />48-02-034 <br />1/23/13 AP /7YFG65E3 MASTERFILE RECORI INFORMATION PINK <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units