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•SANJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility El New EH Program and New Fac FacilityID Z Program Record ID Ros- 401 ili Facility Address 111- 0 . ELthP VA-y\ �F - 39=84wn Gam. aS3"+-t0 (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 ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending 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# tq Mobile Food Prep Unit--Make Vehicle Type Color - ` Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit _ CUPA ❑ Hazardous Materials Business Plan(1900) Number of chemicals: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)---------->-Tons Generated Per Year ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PER(2231) ❑ PBR 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) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing(2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm-------Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use(4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM (4400) A,� ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ SI ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA ❑ Refuse Vehicles p of units) ❑ Dumpsters> 20 cu yd (u of units) ❑ F�irn/R rich C1 up Site MEDICAL WASTE PROGRAM(4500) �C O 10,n ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Geimite� auler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112- 10 10-311 06 � ge rators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue EHD 46-02-003 Blue Application Form OEP`IRTM Np EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSONO`C� n rL�' �S fy') r� Day Ph rll�f 3I Night Ph-26C-) — 9f�-f- )3— �jf f 1 s I PROGRAM ELEMENTq a 1 FEE 2 ❑ SurcIn ge F E ElOther FEE INSPECTOR# ��Sg- I PERMIT VALID � 2� t0 2021 ❑ Food Handler ❑ Check# AMOUNT PAID .� Date 2 U INVOICE# 33 3G ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date S''7f LQ 4/202-034 TERFILE RECORD`NFORMATION PINK 1/23/13 / O PMTIItQ1T