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MERG <br />CONTACT PERSO a/ ht Ph <br />PROGRAM ELEMENT FEE n <br />NOrATION FOR THIS FACILITY AND/OR PROGRAM <br />Le,/ Day Ph .:7 0 V4-, V9-0/ <br />INSPECTOR # ^ PERMIT VALID <br />D Check # AMOUNT PAI <br />Cash REVIEWED BY <br />0 Other FEE <br />LI Food Handler <br />INvoicE# 3/2 787 <br />Date ST3 lir <br />MASTERFILE RECO INFORMATION PINK <br />LI Surcharg FEE <br />S g. to <br />Date Wig <br />l ACCOUNTING OFFICE <br />4B-02-034 <br />1/23/13 <br />SAN JOAQUIN COUNTY El RONMENTAL HEALTH DEPARTl <br />MASTERFILE RECORD INFORMATION FORM <br />EI,New EH Program and New Facility <br />Facility ID r/1001-4- Program Record ID -R4()S-17L3/41 <br />Facility Address 746 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />0 Commissary 0 Dry storage only <br />0/Retail Market----Square footage <br />Pr Mobile Food Vehicle --Make <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />LI Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to El CFO 0A0B <br />DAIRY PROGRAM (2000) <br />El Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program El 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) El PBR HHW (2236) <br />El Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />El Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />El 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 El UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site LI 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 0 Spa El Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />LI Poultry Farm Maximum number of birds <br /> <br />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 />El Body Art Facility-Sterilization (4121) El Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # <br />Pumper Yard 0 Package Treatment Plant 1=1 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />El Landfill 0 Transfer Station LI Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (# of Units) LI Dumpsters > 20 cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care El Skilled Nursing 0 Large Generator El Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility LI 2 - 10 0 11 - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />El New EH Program at Existing Facility <br />Square Footage Food Handlers Course required: YES l "No LI <br />0 with Food Preparation OVending Machines Number of Units <br /> <br /> LI w/Meat Market only El Multiple Departments El Prepackaged Goods Only <br />Vehicle Type Color /,.., License # 1.-//-7 /L ‘..---V I Sticker # <br />Vehicle Type Color <br />License # Sticker # <br />Capacity Vehicle # <br />Sludge/Ash Site <br />0 CIA Landfill Site <br />Farm/Ranch Cleanup Site