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PROGRAM ELEMENT 4-.3 FEE <br />INSPECTOR # /6 W / PERMIT VALID <br />CI Check # AMOUNT F,)AID <br />CI Cash REVIEWED 13q_ _ <br />ef,/li c( <br />e F E CI Other FEE El Surchar <br />to <br />Date <br />CI Food Handler <br />INVOICE # <br />7MAST <br />ERFILE RECO or INFORMATION PINK <br />g&7 Date 23--- ACCOUNTING OFFICE (iS <br />48-02-034 <br />1/23/13 <br />SAN JOAQUIN COUNTY E RONMENTAL HEALTH DEPART NT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility <br />CI New EH Program and New Facility <br />Fac lity ID 7,4DC).2_,-1-7gg Program Record ID -2..Ds-424,y.,,3 <br />Facility Address //00 fe-rc-44,10 S 0 6(M. S;46 9 S71 1 <br />umber of units and pertinent information. <br />Food Handlers Cours re uif-ligft61011) No'IC <br />CI Vending Machines d ail nits 4018 <br />CI Multiple Departments CI (6' ct4 .o4ds Only <br />1--121//r. •1/./711 <br />/3—Lf r <br />(Please check the appropriate description and specify size, n <br />FOOD PROGRAM (1600) <br />CI Restaurant: Seating Capacity <br />CI Commissary ID Dry storage only <br />0 Retail Market----Square footage <br />7f-mobile Food Vehicle --Make <br />Registration # <br />CI Mobile Food Prep Unit-- Make <br />Registration # <br />Square Square Footage <br />CI with Food Preparation <br />El w/Meat Market only <br />Vehicle Type <br />License # <br />Vehicle Type <br />License # / V./Si C? <br />Color <br />Sticker # <br />Color <br />I=1 Temporary Food Facility --Dates of operation from <br />ID Special Event---Dates of operation from to <br />0 Kennel <br />CI Sludge/Ash Site <br />CI CIA Landfill Site <br />CI Farm/Ranch Cleanup Site <br />El > 60 generators <br />CONTACT PERSON <br /> Sticker # <br /> El Ice Plant 0 Produce Stand <br />0 CFO 0 A 0 B <br />to <br />DAIRY PROGRAM (2000) <br />CI Grade A Dairy CI Grade B Dairy CI Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />ID Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program 1:1 Program 1 Facility 0 Program 2 Facility CI Program 3 Facility <br />0 Hazardous Waste Generator (2200) > Tons Generated Per Year <br />CI Tiered Permitting Facility > CI CA (2232) CI CE (2233, 2234, 2235, 2237) 0 PBR (2231) CI PBR HHW (2236) <br />El Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />El Other CUPA Program <br />HOUSING PROGRAM (2400) <br />o 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 />CI Environmental Assessment 0 UST-CAP Site CI Local HW Cleanup Site 0 NPL/SEP Cleanup Site CI UIC Site <br />CI Abandoned HW Site El non-NPL/SEP Cleanup Site CI RWQCB Cleanup Site CI Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility CI Pool CI Spa CI Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />CI Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />ID Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) <br />1:1 Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper Vehicle Registration # License # Capacity Vehicle # <br />CI Pumper Yard CI Package Treatment Plant CI Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill El Transfer Station El Ag/Cannery Waste Site <br />CI Waste Tire Facility CI Compost Facility CI Process/Recycle Facility <br />CI Refuse Vehicles (# of Units) El Dumpsters > 20 cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care El Acute Care CI Skilled Nursing 0 Large Generator CI Small Generator 0 Limited Hauler <br />CI Transfer Station CI Veterinary Clinic CI Common Storage Facility 0 2 - 10 CI ii - 60 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application Form <br /> <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph 6-'10/Night Ph