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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PAYMENT <br /> MASTERFILE RECORD INFORMATION FORM RECEIVED <br /> 13 `Program at Existing FacIII!X ®New EH Pro grarriand New Facility DECI 5 20% <br /> =FacifitylD f'Ab006,6&,5-- Program Record 10 LEQS <br /> HE.ALT'I4 DepA.RTV0,rr <br /> Facility Address <br /> 9919 Kent Street, Elk Grove,CA 95624 <br /> (Please check the appropriate description and specify size,number of units and pertinent Information.) <br /> FOOD PROGRAM(1600) <br /> 1:1 Restaurant: Seating Capacity,_„ Square Footage Food Handlers Course reguired! YES IJ NON] <br /> E3 Commissary 0 Dry storage only 13 with rood Preparation OVending Machines Number of Units <br /> IJ Retail Market---Square Square footage— 0 w/Moat Market only 13 Multiple Departments M Prepackaged Goods Only <br /> Mobile Food Vehicle—Make GMC Vehicle TypeTC5C042 w/fineezerbox Color Gold <br /> Registration#_LcADjicic,5(iF9nalo(, License# 7V68562 Sdcker#.5L127L__ <br /> E3 Mobile Food Prep Unit..Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> 0 Temporary Food Facility—Dates of operation from to IJ lea Plant 13 Produce Stand <br /> El Special Event--Dates of operation from to E3 CFO 0 A EI B <br /> DAIRY PROGRAM(2000) <br /> 0 Grade A Dairy 0 Grade 8 Dairy El Milk Dispenser-Number of Containers In Multi-Head Unit_ <br /> CUPA <br /> 13 Hazardous Materials Business Plan(1900) Number of chemicals; <br /> 13 CaIARP Program 13 Program I Facility 13 Program 2 Facility 13 Program 3 Facility <br /> 0 Hazardous Waste Generator(2200)------> Tons Generated Per Year ---- <br /> 13 Tiered Permitting Facility-----> 13CA(2232) E3CE(2233,2234,2235,2237) CIPBR(2231) OPBAHHW(2236) <br /> 13 Aboveground Storage Tank Facility(AST) (2800) Number of ASTs_ <br /> 0 Underground Storage Tank Program(UST)(2300)Use UST and 8 form <br /> 0 Other CUPA Program <br /> HOUSING PROGRAM(2400) <br /> IJ Hotel/Moto)-----Number of Units 13 Jail or Exempt Institution....Number of Units <br /> Employee Housing(2700)Use F—Molovee HousinglL bar Caren Applicadon Foun <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 13 Environmental Assessment 13 UST-CAP Site E3 Local HW Cleanup Site 1:1 NPLISEP Cleanup Site 11 UIC Site <br /> 171 Abandoned MW Site 11 non-NPLISEP Cleanup Site 0 RWQCB Cleanup Site 13 Water Quality Ramedlation Site <br /> RECREATIONAL HEALTH PROGRAM(36010) <br /> Number of Pools/Spas at Facility 11 Pool 0 spa El out of Service Pool/Spa 13 Natural Bathing Area <br /> VECT014 CONTROL PROGRAM(4000) <br /> 0 Poultry Farm------Maximum number of birds IJ Kennel <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> • Body Art Practitioner Reg(4110) El Mechanical DSPS Notification(4115) EJ Body Art Facility-Single Use(4120) <br /> • Body Art Facility-Sterilization(4121) OBody Art Temp Event Co-ord(4130) OBody Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> 0 Pumper Vehicle Registration# License# Capacity_ Vehicle# <br /> 0 Pumper Yard 13 Package Treatment Plant IJ Chemical Toilets'---Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> 11 Landfill 1:1 Transfer Station D AgICannory Waste Site IJ Sludge/Ash Site <br /> 1:3 Waste Tire Facility 0 Compost Facility M Process/Recycle Facility 0 CIA Landfill Site <br /> E! Refuse Vehicles(ft of units) 13 Dumpsters>20 cu yd I*of Units)^ 0 Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> 13 Primary Care 13 Acute Care IJ Skilled Nursing 12 Large Generator 11 Small Generator 13 Limited Hauler <br /> OTransfer Station 1:3 Veterinary Clinic IJ Common Storage Facility IJ 2-10 El 11 -60 0 >60 generators <br /> PUBLIC WATER.SYSTEM PROGRAM(4600) Use FINS EHD 46-02-003 Blue Apolicaffon Form <br /> EMERGENCY NOTIFICATION FOR THIS FACIhITY 6NIoR PROGRAM <br /> CONTACTPERSONJayJohnson Day Ph Night Ph.-..... <br /> PROGRAM ELEMENT ,',� -�P FEE 60 <br /> 0 Surcharge FEE 0 Other FEE <br /> - a"7 <br /> INSPECTOR# Z:13�gZ� PERMITVALID to 1? 31/ 13 Food HaIndler <br /> tr<heck <br /> 70 AMOUNT PAID �J(a) Da INVOICE# 2 <br /> 13 Cash REVIEWED BY AccouNTING OFFICE Date 16 <br /> 40-02034 MASTrFIFILEI CORD INF RMATIONPINK <br /> 1123/13 <br />