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bhy.11.2020 21:54 #0133 P 2 Rn" HOD PgYMEN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED MASTERFILE RECORD INFORMATION FORM MAY 2 New EH Pro ram at Existing Facility ❑New EH Program and New Facility ��2� Facilit ID D ZS�l�� Program Record ID Hq N RONMEC�q NTy Facility Address ,� � 1 �� n1ENT (Please check the appropri to descrlptlon and specify size, n ber of units and Dertlnent In rmation.) FOOD PROGRAM(1600) �llk)G k� JS+(W ❑ Restaurant: Seating Capacit Square Footage Fool Handlers Course required: YEsk No LJ ❑ Commissary El Dry storage only El with Food Preparation []V�nding Machines Number of Units ❑ Retail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit.-Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to El lee Plant 11Produce Stand ❑ Special Event---Dates of operation from to ❑ CFO CIAO B DAIRY PROGRAM (2000) 1`M ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA O Hazardous Materials Business Plan(1900) Number of chemicals: i ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility; CI Program 3 Facility ❑ Hazardous Waste Generator(2200)---------->-Tons Generated Per Year ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE(2233,2234, 2235,237) ❑ P13R(2231) ❑ PSR HHW(2236) ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs ❑ Underground Storage Tank Program(UST)(2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM(2400) 11Hotel/Motel------- Number 0 nits ❑ Jail or Exempt Institution----Number of Units Employee Housing(2700) Use Emp/one HousinglLabor CatM Apollcatlon Form SITE MITIGATION(2900) T1 UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site I ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SI�P Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remedlatlon Site RECREATIONAL HEALTH PROGRAM(3500) Number of Pools/Spas at Facility ❑ Pool ❑ Spa 13Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm-------Maximum number of birds �f ❑ Kennel TATTOO.BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) 1�/ ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use(4120) El Body Art Facility-Sterilization (4121 ❑Body Art Temp Event Co-ord (4130)! ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) NI ❑ Pumper VehleleRegistration# License# Capacity Vehicle# ❑ Pumper Yard ❑,Package Treatment Plant ❑ Chemical Toilets --Number of Units SOLID WASTE PROGRAM(4400) Pf rel ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(a of units) ❑ Dumpsters>20 cu yd!(u of untie) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limped Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility P 2-10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHQ 46-02-003 Blue Application Form EMERGENCY NOTIFICATION F:QR YNis FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT �g FEE Ob ❑ Surchar e F E ❑ Other FEE It N$PECTOR# PERMIT VALID to S 3 ❑ Food Handler eck# 7 AMOUNT PAID •60 Date S INVOICE#sh REVIEWED BY ACCOUNTING OFFICE Date V-2 40-02-034 MASTERFILE RECO D INFfORMAI ION PINK Received Time May, 12. 2020 10 : 54AM No, 5983