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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM 0 New EH Program at Existing Facility ew EH Program and New Facility Facility ID Program Record ID Facility Address-A-9Lq_yj�if I Y._ L9_Lgr— It X5336 (Please check the appropriate description and specify Size number of units and Pertinent information.) FOOD PROGRAM(1600) 0 Restaurant Seating Capacity____ Square Footage------- Food Handlers Course required: YES[] NoEl 0 Commissary 0 Dry Storage only O with Food Preparation OVending Machines Number of Units 11 Retail Market—Square footage 0 wAleat Market only 0 Multiple Departments 0 Prepackaged Goods Only 0 Mobile Food Vehicle—MakeVehicle Type ___ Color Registration#_----- License#___________ Sticker#-- 0Mobile Food Pre Unit—Make _ P _______ Vehicle Type _ Color_____________ Registration# _ __________ _ _ _ _ —__ ________ License# Sticker# ❑Temporary Food Facility—Dates of operation from______--- to _ 0 Ice Plant O Produce Stand _—_—_ 0 Special Event—Dates of operation from________________ to ......__________ CFO�A 0 B DAIRY PROGRAM(2000) 0 Grade A Dairy 0 Glade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit COPA 0 Hazardous Materials Business Plan(1900) Number of chemicals: 0 CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility 0 Hazardous Waste Generator(2200)-------->-Tons Generated Per Year__ -- 13 Tiered Permitting Facility------> 0 CA(2232) 0 CE(2233,2234,2235,2237) 0 PBA(2231) 0 PBR HHW(2236) 0 Aboveground Storage Tank Facility(AST)(2800) Number of ASTs 0 Underground Storage Tank Program(UST)(2300)Use USIA and B forms 0 Other COPA Program _______._____________ HOUSING PROGRAM(2400) ff HotebMotel---Number of Units __________ 0 Jail or Exempt Institution—Number of Units _________ Employee Housing(2700)Use Empfoyee Nousinp/Lsbor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) 0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPUSEP Cleanup She 0 UIC Site 0 Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Duality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Poole/Spas at Facility ___ 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area VECTOR CONTROL PROGRAM(4000) 0 Poultry Farm—Maximum number of birds0 Kennel TATTOO,BODY PIERCING.PERMANENT COSMETIC PROGRAM(4100) 0 Body Art Practitioner Reg(4110) 0 Mechanical DSPS Notification(4115) 0 Body Art Facility-Single Use(4120) 0 Body Art Facility-Sterilization(4121) 0 Body Art Temp Event Coord(4130) 0 Body Art-Temp Event Mobile Facility(4131) LIOUID WASTE PROGRAM(4200) 0 Pumper VehicleRegistration#___-----_--- License#___ _ Capacity ------___ Vehicle# 0 Pumper Yard O Package Treatment Plant 0 Chemical Toilets--Number of Units_________ SOLID WASTE PROGRAM(4400) ❑ Landfill ❑Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash SitePArjWEV?. ❑ Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill S' ��''ii ,II 0 Refuse Vehicles(#of unim) ___ 0 rm Dumpsters>20 cu yd(#of unn) _____ 0 Fa /Ranch�V T.F MEDICAL WASTE PROGRAM(4500) 0 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limit ,17gT� 0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 112-10 0 11-60 0 >60 gen r rS9 2020 PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02.003 Blue Application Form SAN JOAQUI MERGENCY NOTIFICATION FOR TNISFACLITY ANGOR PROGRAM ��AaENV/RO NCOUN7y CONTACT PERSON_ 'U I'll DayP Z'�-_�L NightP � 17 ENTAL PROGRAM ELEMENT_ ___ FEE 0 Surcharge FEE_______ 0 Other FEE T INSP croR#___________ PERMIT VALID __ __ to______ _ _ 0 Food Handler AMOUNTPAID ��i��__ Date _Ibj�— 2b INVOICE#______________ ❑ Cash REVIEWED BY ACCOUNTING OFFICE Lim Date ".02-034 MASTERFILE RECORD INFORMATION PINK 71=3