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PA SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT R CE VED MASTERFILE RECORD INFORMATION FORM JAN❑New FH Program at ExistingFacility ❑New EH Program ane New Faeili JAN � � 202, Facilit ID / Program Record ID 20,5 SAENOONAQJIN cp J Facility Address -'1 9 McPartd4 Rd. 6SCl;d0Y1,CA °1.5.32NE0 ALTN p NTA ME NTY (Please check the appropriate description aM sW..4 size number of units and pertinent information.) EPARTfv7ENT 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 Jnfts ❑Retall 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 Venice Type Color Registration# License# Slicker# ❑ Temporary Food Facility—Dates of operation from to _ ❑ I Plant 13 Produce Stand 13 Special Event—Dates of operation from _ to �FO �A ❑ H DAIRY PROGRAM(2000) ❑Grade A Dairy ❑ Grade 8 Dairy ❑ Milk Dispenser-Number of Cnmainam In Multi-Head Unit _ CUPA ❑ Hazardous Materials Business Plan(1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)--->-Tons Generated Per dear ❑ Tiered Permitting Facility--> ❑CA(2232) ❑CE(2233,2234, 2235,2237) ❑ POR(2231) ❑ PBR HHW(2236) ❑ Abovaground Storage Tank Facility(AST)(2800) Number of ASTs ❑Underground Storage Tank Program(UST)(2300)Use LISTA arra B forrbs ❑Other CUPA Program _ HOUSING PROGRAM(2400) ❑ HOtsllMotel---Number of Units ❑ Jail or Exempt Institution ---Number of Units Employes Housing(2700)Use Embiotme Housinci,05 bor Camp Application Form SITE MITIGATION!2900) UNDERGROUND NJECTICN CONTROL!3000) ❑ Envlronmerdal Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑NPUSEP Cleanup Site ❑ UIC site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQC13 Cleanup Site ❑Water Quality RemedlatlOn She RECREATIONAL HP-ALTH PROGRAM(3600) Number of Pools/SPas at Facility _ ❑ Pool ❑ Spa ❑Out of Service P"I/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm—Ma>umum number of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT C06METC PROGRAM(4100) ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body AR Facility-Single Use(4120) ❑ Body Art Facility-Sterilization(4121) ❑Body Art Tamp Event Coord(4130) ❑ Body Art-Temp Event Mobile Facility 14131) LIQUID WASTE PROGRAM(420D1 ❑ Pumper VehicleRegisirabon# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets---Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash site ❑ Waste Tire Facility ❑ Compost Facility ❑ Processfftecycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(w cf unas) ❑ Durnpsters>20 cu yd(a of unu ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 1111 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PAYS EHD 40-02-003 Blue Apallcation Form R aNCY NoFICATION FOft TPROGRAM CONTACT PERSON Day Ph 2lXA 071-"1 01� Night Ph 'lDQ 1-'IUjl I PROGRAM ELEMENT 6g FEE •Da ❑ SurchIr eF E ❑ Other FEE IINN,SPFCTOR# PERMIT VALID Z to 13 Food Handier Itl Checks AMOUNT PAID Date 2- INVOICE# /- �LLJ Ce6n RCVIEWED a" AccouNTING oh cit Date 3 2� 48-32-034 M4STERFI FRF(.O n INFORMATION PINH f 23/f 3