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0 Surcharge FEE 0 Other FEE to — - k2.-11-23 I p Date 12-W2 ACCOUNTING OFFICE 0 Food Handler INVOICE # Date 11 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility ONew EH Program and New Facility Facility ID FAOO77 7,S" Program Record ID ?R_D61-PgX2-77 Facility Address 12\ 1(\1\C• (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only obile Food Vehicle --Make rit )miA -ry Vehicle Type LAIC LOSF T PA colo6i4/ Registration # License # VK 2-57 X - Sticker # Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand Special Event---Dates of operation from to 0 CFO 0 A 0 B DAIRY PROGRAM (2000) Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit CUPA Hazardous Materials Business Plan (1900) Number of chemicals: CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility Hazardous Waste Generator (2200) >-Tons Generated Per Year Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) Aboveground Storage Tank Facility (AST) (2800) Number of ASTs Underground Storage Tank Program (UST) (2300) Use UST A and B forms Other CUPA Program HOUSING PROGRAM (2400) Hotel/Motel Number of Units 0 Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) Poultry Farm Maximum number of birds 0 Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) Pumper Vehicle Registration # License # Capacity Vehicle # Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill SitPA, Refuse Vehicles (# of Units) 0 Dumpsters >20 cu yd (# or units) 0 Farm/Ranch Ate MEDICAL WASTE PROGRAM (4500) /WO Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limitilitalei Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 0 Acig 98n eratofs 2023 PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS El-ID 46-02-003 Blue Application Form EivguiN Co" EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM ilEALTH a, sz _INNZITY CONTACT PERSON fr)417) S 'Ai H Day Ph •109 ( OD 2— Night Ph —2_09 .j5 C)10,30 PROGRAM ELEMENT \(:)S. FEE INSPECTOR # GI \--- PERMIT VALID O Check # AMOUNT PAID Q7CaShiiYi. REVIEWED BY 48-02-034 MASTERFILE RECORD IN ORMATION PINK 1/23/13