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PA SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT R CE VED MASTERFILE RECORD INFORMATION FORM A t' ❑New FJH Program at Existing ty ❑New EH Program and New Facili JAN 1 1 20?, Facility ID / Program Record ID 20,5 SAENOAQJiN co J Facility Address -'1 9 MCPYldt RA. FSC0.10Y1,CA -I319,0 NEALTf IoNeNTA�Ty (Please check the appropriate description ant spec-Ify same number of units and pertinent information.) EPARTf"IENT 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 ❑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 Venice Type Color Registration# License# Sicker# ❑ Temporery Food Facility-Dates of opeation from to _ 131 Plant❑ Produce Stand ❑ Special Event—Dates of operation from _ to �FO A ❑ H DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade 8 Dairy ❑ Milk Dispenser-Number of Containers 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) ❑ PBR(2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST)(2800) Number of ASTs ❑Underground Storage Tank Program(UST)(2300)Use OST A arrd B fbrms ❑Other CUPA Program HOUSING PROGRAM(2400) ❑ HotellMotel---Number of Units ❑ Jail or Exempt Institution ---Number of Units Employee Housing(2700)Use Employee Housincii5bor Camp Application Form SITE MITIGATION i2900) UNDERGROUND NJECTICN CONTROL!3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑NPUSEP Cleanup Site ❑ UIC site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑Water Quality RemediatlOn Site RECREATIONAL HCALTH 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—Matumum number of birds ❑ Kennel TATTOO BODY PIERCING PERM/WENT COSMETIC P9998 M(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 Coord(413C) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(42001 ❑ 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 ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles 0 cf unzs) ❑ Durnpsters>20 cu yd ice of un" ❑ FamVRanch 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 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PVM EHD 4"2-003 Blue Apoilcation Four NCATION Fort r I PROGRAM CONTACT PERSON R awcr No Day Ph 2lXA OILLj sty Night Ph 'AlaA& -' w PROGRAM ELEMENT L)g FEE •Da ❑ SurchIr eF E ❑ Other FEE IwapEdroa$ PERMITVALID Z t0 ��,,,,//// ❑ Food Handclgr Itl Check 7 AMIXIM PAIDK&i z Date 2 INVOICE /- Casa RZVICWEDB� AccouNTirG Orrice Date 48-32-034 M43TERF1 FRF(.O D INFORMATION PINH 123M