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CI Other FEE <br />0 Food Handler <br />INVOICE # — <br />Date 5— 2 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />CONTACT PERSON <br />New EH Program at Existing Fac2ty___ <br /> <br />ONew EH Program and New Facility <br /> <br />Facility ID Ft Dc).2.5? <br />Facility Address 1C 2.0 ( daelau g . ZaViinig tiçt 3(7 <br />(Please check the appropriate description <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />yi41obile Food Vehicle --Make c <br />CI Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />Progxn Record ID PRZ 7-1-102Y <br />and specify size, number of units and pertinent information.) <br />Square Footage <br />with Food Preparation <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />A <br />w/Meat Market only 0 Multiple De;4rtm <br />Vehicle Type A U Color tee <br />ense # v(lei <br />Vehicle Type <br />License # <br />AP119 n u 2n,, <br />Ds A vi oivmAi NouNry <br />SA4i bi 04010_, <br />""Dep ART <br />Food Handlers Course required: YES 0 N <br />(=Wending Machines Number of Units <br />ts 0 Prepackaged Go 9 ds Only <br />Sticker # <br />Color <br />Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />to CI CFO CIA 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 />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 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 <br /> <br />O 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 <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 />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 />0 Pumper Yard CI Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (# of Units) 0 Dumpsters > 20 Cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care CI Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility CI 2- 10 0 11 -60 0 >60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EffRGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />ft.asvi Day Ph .21:711.7,2-10,4 Night Ph 'dm Q..- <br />PROGRAM ELEMENT <br />INSPECTOR # <br />Check # <br />Cash <br />FEE .Sr. Fr4,1 din a„ <br />El Surchar e F <br />to 12-3 <br />Date <br />PERMIT VALID <br />AMOUNT PAID <br />REVIEWED BY ACCOUNTING OFFICE <br />48-02-034 MASTERFILE R OR INFORMATION PINK <br />1/23/13 <br />tv v.Aivt'uf <br /> <br />ebni t 177 3467