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ACCOUNTING OFFICE REVIEWED BY <br />INSPECTOR # <br />0 Check # <br />Cash <br />48-02-034 <br />1r23/13 <br />0 Other FEE <br />0 Food Handler <br />2-b1 INVOICE # 3/1 <br />Date <br />MASTERFIL R CORD INFORMATION PINK <br />PROGRAM ELEMENT j C FEE 0 Surc <br />PERMIT VALID /1 7/0 2,3 to <br />AMOUNT PAJD 714 Date <br />i69 1/1/1-12-t, <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility <br />Facility ID M1-70 /1'1, 11 <br />Facility Address \V;SD U3. Oc G15 (_0(0 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />Retail Market--Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle -Make Vehicle Type Color <br />Registration # License # Sticker # <br />0 Mobile Food Prep Unit- Make Vehicle Type Color <br />Registration # License # Sticker # <br />0 Temporary Food Facility -Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event—Dates of operation from to SCFO qAim3 <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 'I 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 />0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 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 />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPLJSEP Cleanup Site 0 UIC Site <br />0 Abandoned HW Site 0 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 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) 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />0 Pumper VehicleRegistration # License # Capacity vitest <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets —Number of <br />un V D rEcVIVIENEET <br />0 Ag/Cannery Waste Site <br />0 ul <br />0 Large Generator 0 Small Generator 0 <br />0 Process/Recycle Facility <br />ft Farm/1414iaZIN Site <br />0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 0 > 60 generators <br />, n l i UCPART: <br />L <br />i <br />mi <br />t <br />ed Hau r <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application Form <br />EMERGENCY NO11FICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON .V\W-IV)-e (-17-1c-W\•-' Day Ph 000140- 0,7 (61 Night Ph6Q0c1-)-10AD - 5'r-1 <br />-aNew EH Propram and New Facility <br />Program Record ID fitP0'31 2-- <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />0 Waste Tire Facility 0 Compost Facility <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing <br />Refuse Vehicles of Units) 0 Dumpsters > 20 cu yd ( of Units) 0 <br />siud4a, 2023 <br />CIA Landfill Site coutay <br />Scanned with CamScanner