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PROGRAM ELEMENT 1tc. ?")L 3 FEE 1. 231 0 Surcharge FEE <br />PERMIT VALID B 2 23 to V2-I 3t12 <br />23 AMOUNT PAID di Date IP <br />REVIEWED BY ACCOUNTING OFFICE <br />0 Other FEE <br />ID Food Handler <br />INVOICE # • 7Z7D <br />Date opt <br />INSPECTOR # <br />Check # <br />LIC <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility <br />Facility ID <br />Facility Address Li ii <br />Chew EH Program and New Facility <br />Program Record ID -P/U2454+52 - <br />lit VII 0 \A S, I- SI NC 121.04 CA 0)S20.40 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 <br />Commissary 0 Dry storage only CI with Food Preparation [Wending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />CI Mobile Food Vehicle --Make ST _Vehicle Type \,164 Y )e 61 Color <br />Registration #-ii qui 1 aornst,01-?License # Li U\ e s 0 LA \ Sticker <br />tt <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant D Produce Stand <br />Special Event---Dates of operation from to 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 > LI 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 />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />LI 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 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 LI Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br /> D 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 />Pumper VehicleRegistration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />Primary Care 0 Acute Care 0 Skilled Nursing LI Large Generator 0 Small Generator <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 11 <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 />CONTACT PERSON tU\Cit Y \Cit 60 sr-) Day Ph lOi 6iI1, 5V t) Night Ph <br />48-OZ-034 <br />1/23/13 lteCeS132&,ete <br />MASTERFILE RECe'D INFORMATION PINK <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />LI Ag/Cannery Waste Site <br />0 Process/Recycle Facility <br />LI Dumpsters > 90 cu yd (# of Units) <br />0 Sludge/ lEittAir <br />0 CIA Land i "SOf <br />LI Farm/Rive 9,lean4`giie <br />u 2 2op <br />"•.4...multpci Hau <br />Air-ZakiAtto <br />" ON;i7. ritt <br />4147. <br />.1/0 0