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SAN JOAQUIN COUNTY E IRONMENTAL HEALTH DEPAR" NT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility CINew EH Program and New Facility Facility ID rikr5 7- -0 - Si...1-c\ Program Record ID ?LC 5-.\-q --47„ Facility Address 2 9100 - A-I-A0A1f ty. r1 /1 c71-v4.1 1 52_ 0 5 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No l=1 CI Commissary I=1 Dry storage only 0 with Food Preparation ElVending Machines Number of Units etail Market----Square footage 0 IR _ ye CI w/Meat Market only 0 Multiple Departments CI Prepackaged Goods Only Mobile Food Vehicle --Make Vehicle Type Color Registration # License # 3T---ticker # Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # CI Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand Special Event---Dates of operation from to GI CFO 0 A 0 B DAIRY PROGRAM (2000) El Grade A Dairy 0 Grade B Dairy Milk Dispenser -Number of Containers in Multi-Head Unit CU PA ID Hazardous Materials Business Plan (1900) Number of chemicals: CalARP Program CI Program 1 Facility CI Program 2 Facility 0 Program 3 Facility CI Hazardous Waste Generator (2200) > Tons Generated Per Year CI Tiered Permitting Facility > 0 CA (2232) CI CE (2233, 2234, 2235, 2237) CI PBR (2231) PBR HHW (2236) CI Aboveground Storage Tank Facility (AST) (2800) Number of ASTs CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms Other CUPA Program HOUSING PROGRAM (2400) Cl Hotel/Motel Number of Units 0 Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) El Environmental Assessment 1:1 UST-CAP Site CI Local HW Cleanup Site CI NPL/SEP Cleanup Site CI UIC Site CI Abandoned HW Site non-NPL/SEP Cleanup Site CI RWQCB Cleanup Site CI Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility CI Pool 0 Spa CI Out of Service Pool/Spa 1:1 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) CI Poultry Farm Maximum number of birds CI Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) Cl Mechanical DSPS Notification (4115) CI Body Art Facility-Single Usetcotiili 0 Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event mPATPIIM 4131) LIQUID WASTE PROGRAM (4200) CI Pumper Yard CI Package Treatment Plant CI Chemical Toilets ----Number of UnvitesRhicEleC # El D CI Pumper VehicleRegistration # License # Capacity Landfill El Transfer Station CI Ag/Cannery Waste Site i=1 MAY 17 2019 SOLID WASTE PROGRAM (4400) 1E1 Waste Tire Facility CI Compost Facility CI Process/Recycle Facility El Dumpsters > 20 cu yd (# of Units) El Farm/Ranch Cleanup Site El Slut444%VeNi'l L-1 CIA BEAR' WARTMENT CI Refuse Vehicles (# of Units) MEDICAL WASTE PROGRAM (4500) 0 Primary Care CI Acute Care 0 Skilled Nursing CI Large Generator CI Small Generator 0 Limited Hauler CI Transfer Station El Veterinary Clinic CI Common Storage Facility El 2 - 10 El 11 - 60 CI > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application F0177 -1 EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON 4An C Ptiroyz-rw-A Day Ph 2i4-- 1-cj \ Night Ph 1-01 -501- 51-7 PROGRAM ELEMENT FEE ---- El Surchar e 0 Other FEE INSPECTOR # g -1 %VII, PERMIT VALID to CI Food Handler $5"11AmouNT PAID Date -WPM , VOICE # II CI Cash REVIEWED BY UOir\., ACCOUNTING OFFICE Date pq 48-02-034 MASTERFILE R 0 D INFOR ATIO PIN 1/23/13