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Date 110 <br />ASTERFILE R <br />/1'o1-7 <br />CORD INFORMATION PINK <br />0 Other FEE <br />ID Food Handler <br />IA? L INvoicE# <br />Cash <br />48-02-034 <br />1/23/13 <br />REVIEWED BY <br />to <br />Date <br />ACCOUNTING OFFICE <br />0 Surcharge FEE <br />16. 2'34 0 <br />PROGRAM ELE <br />INSPECTOR # <br />Check # <br /> FEE <br />PERMIT VALID <br />AMOUNT PAID <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION F RM <br />New EH Program at Existing Facility <br /> <br /> New EH Prong _ram and New Fa "lity <br />Program Record ID <br />Facility Address analo Avccio <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 <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 <br />Facility ID ral,TD 2-11 61 61 <br />Vehicle Type <br />Food Handlers Course required: YES 0 No 0 <br />I:Vending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />License # Sticker # Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />to lce4lant 0 Produce Stand <br />z Vehicle Type Color <br />License # Sticker # <br />to CFO 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 />El 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 />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 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 <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # Capacity <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets <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 />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2- 10 0 11 -60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON -RI \ `-) Day Ph (.0(11.--Y31-kr)3S Night PhC )--L-n'35 <br />EMERGE CY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />v.F_RAR- <br />PAYMENT <br />RECEIVED <br />Art Facility-Single Use (4120) <br />Art-Temp Eveffigicibi !Nay (4131) <br />SAN Jcp...4w.ly gOUNTY <br />NVIRS_NWNTAL-----NumbefigALJn4TmEN-T--- <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (# of Units) <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site