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CONTACT PERSON <br />PROGRAM ELEMENT i (-- FEE i< <br />INSPECTOR # /?O PERMIT VALID <br />CI Check # A OUNT PAID <br />Cash, r REVIEWE <br />\ <br />1/23/13 <br />r Day Ph 7 - 1% Night Ph <br />/-1 <br />48-02-034 <br />0 Surcharge F E CI Other FEE <br />6 <br />Date 7/7S---- <br />MASTERFILE RECO INFORMATION PINK <br />0 Food Handler <br />INVOICE # 469. r <br />to 1 3/ <br />Date <br />ACCOUNTING OFFICE <br />Food Handlers Course required: YES No 0 <br />PAYMENT <br />RECEIVED <br />JUL 1 7 2015 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY /IRONMENTAL HEALTH DEPAI <br />MASTERFILE RECORD INFORMATION FORM <br />ENT <br />CI New EH Program at Existing Facility \20 New EH Program and New Facility <br />Facility ID r,4cc.D.Z3`i 7 Program Record ID i7W5-17LL-- 3/ 7 <br />Facility Address / 7 7 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br /> <br />CI Restaurant: Seating Capacity Square Footage <br />Commissary CI Dry storage only 0 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />Mobile Food Vehicle --Make <br />Registration # <br /> <br />_(Mobile Food Prep Unit-- Make Vehicle Type tri <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from to <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 'I Facility CI Program 2 Facility CI Program 3 Facility <br />Hazardous Waste Generator (2200) > Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) CI CE (2233, 2234, 2235, 2237) CI 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 CI 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 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 U1C Site <br />Abandoned HW Site El non-NPLJSEP 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 CI Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />El Poultry Farm Maximum number of birds CI Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) <br />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 />Pumper Yard 0 Package Treatment Plant CI Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill 0 Transfer Station El Ag/Cannery Waste Site <br />Waste Tire Facility CI Compost Facility CI Process/Recycle Facility <br />Refuse Vehicles (# of Units) El Dumpsters > 20 cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing CI Large Generator CI Small Generator <br />CI Transfer Station CI Veterinary Clinic CI Common Storage Facility CI 2 - 10 CI 11 - 60 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Vehicle Type Color <br />License # Sticker # <br />3& Color <br />License # Sticker # 2c3-7) <br />to 0 Ice Plant 0 Produce Stand <br />0CF0 0A0B <br />CI Sludge/Ash Site <br />I=1 CIA Landfill Site <br />0 Farm/Ranch Cleanup Site <br />CI Limited Hauler <br />El > 60 generators