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ifrNew EH Program at Existing Facility <br />Facility ID PACO2:7 L/111 <br />ONew EH Program and New Facility <br />Program Record ID ri2D5-%-fs 1 <br />=ZEVIEWED BY <br />PROGRAM ELEMENT I 0 <br />INSPECTOR # D/4R1 <br />vheck # <br />LI Surcha ge FEE <br />to <br />Date <br />ACCOUNTING OFFICE <br />0 Other FEE <br />1:1 Food Handler <br />INVOICE # 376 <br />Date /2/2-/22-- <br />PERMIT VALID <br />AMOUNT PAID <br />FEE <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility Address 3S-- CD <br />(Please check the appropriate description and <br />FOOD PROGRAM (1600) <br />Commissary 0 Dry storage only <br /> <br />El Restaurant: Seating Capacity <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br /> <br />Registration # <br /> <br />1:1 Mobile Food Prep Unit-- Make <br /> <br />Registration # <br />El Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from to <br /> <br />0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />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 />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 />LI Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Ei 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 />I=1 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 LI Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # <br />LI Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (41 of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled <br />Transfer Station 0 Veterinary Clinic <br />PROGRAM (-5 ---Ct•-5-3g5- <br />Day Ph Ph Night Ph <br />K) J/ti rl <br />specify size, number of units and pertinent information.) <br />Square Footage <br />0 with Food Preparation <br /> LI w/Meat Market only <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Vehicle Type Color <br />License # Sticker # <br />Vehicle Type Color <br />License # Sticker # <br />Food Handlers Course required: YES 0 No 0 <br />to 0 Ice Plant 0 Produce Stand <br />LI Body Art Facility-Single Use (4120) <br />0 Body Art-Temp Event Mobile Facility (4131) <br />Capacity Vehicle # <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR <br />/ PAN t ea LI Sludge/As inh _r <br />0 CIA LancWite 'CD <br />LI Farm/Ranatidatiugite <br />AQI <br />Nursing 0 Large Generator 0 Small GeneratopY <br />etzio <br />hlry <br />0 Common Storage Facility 0 2-10 0 11 - 60 iitifs <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON P4-- <br />CI Ag/Cannery Waste Site <br />0 Process/Recycle Facility <br />LI Dumpsters > 20 cu yd (# of Units) <br />0 Chemical Toilets ----Number of Units <br />84^ido 22 <br />48-02-034 MASTERFILE RECORO INFORMATION PINK <br />1/23/13