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REVIEWED BY ACCOUNTING OFFICE <br />Food Handler <br />4 INVOICE Pf <br />Date 4/ <br />AS-f-E—R—F ILE R 0 D N ORMATION PINK <br />PROGRAM ELEMENT FEE $3 5 Surch <br />Check # <br />Cash <br />48-02-034 <br />1/23/13 <br />INSPECTOR # 9828 <br />VNA <br />PERMIT VALID Z/2492 2 ,to <br />Amou T PAID / Date <br />44- i ,C1U iq 7 <br />Other FEE <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility lNew EH Program and New Facility <br />Facility ID Program Record ID Lt ô 5 <br />Facility Address 4170 F WATERLOO RD/COL1\J 1%21 <br />(Please check the appropriate description and specify size, number of units <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # <br />Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from to <br />and pertinent information.) <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />to 0 Ice Plant 0 Produce Stand <br />Sticker # <br />Color <br />Sticker # <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) <br /> Number of chemicals: <br />LI 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) <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 0 Jail or Exempt Institution <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site <br />Abandoned HW Site LI non-NPLISEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <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 # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Landfill 1:1 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (nor uniis) <br />MEDICAL WASTE PROGRAM (4500) <br />El Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br /> <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON k r•—(7.A., t•J Day Ph Zoe( - - (ac Li Night Ph 2- u c, - 2-At -CC 2- g\ <br />PBR (2231) 0 PBR HHW (2236) <br />----Number of Units <br />UIC Site <br />Site <br />0 Spa 0 Out of Service Pool/SPAYMENTI Bathing Area <br />RECVED <br />Kennel <br /> License # Capacity <br />0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />JUL 2 0 2023 o Body Art Facility-Single Useail120) <br />0 Body A ditti EIMAIM acility (4131) A <br />HEALTH DEPARTMENT <br />Vehicle # <br />Ag/Cannery Waste Site 0 Sludge/Ash Site <br />Process/Recycle Facility 0 CIA Landfill Site <br />Dunipsters > 20 Cu yd (ti or units) 0 Farm/Ranch Cleanup Site <br />0 Limited Hauler <br />0 > 60 generators