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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />II Facilitv ID 1�14C/U.440 /,g[) Proaram Record ID -rV?)C 11+ / LSL I <br />PAYiWENr <br />RECEIVED <br />AUG 18 ?021 <br />Facility Address 1 --,So 5, C-jo,l A *b(n cA <br />SA , SAN JOAQUINCOUN <br />(Please check the appropriate description and specify size, number of units and pertinent information.) ENVIRONMENT TY <br />FOOD PROGRAM (1600) <br />HEALTH DEPARALT <br />EW <br />❑ Restaurant: Seating Capacity Square Footage <br />Food Handlers Course required: YES ❑ No Lf <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑Vending Machines Number of Units <br />❑ Retail Market ----Square footage ❑ w/Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />&Mobile Food Vehicle --Make Vehicle Type <br />Color Ary%0,Yi 0()Registration <br /># <br />license # <br />S? �� 143 Sticker # <br />Mobile Food Prep Unit-- Make OA( t 7-0 14ehicle <br />Type <br />Color <br />Registration # License # <br />Sticker # <br />❑ Temporary Food Facility --Dates of operation from <br />to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to <br />❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200) -------- —>-Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PBR HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # <br />❑ Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />License # <br />❑ Package Treatment Plant <br />Capacity Vehicle # <br />❑ Chemical Toilets ----Number of Units <br />❑ Landfill ❑ Transfer Station ❑ AglCannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd )# of Units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 11 -60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON ircD f i 4 E, A I hwar Day Ph 209-636-1397 Night Ph <br />PROGRAM ELEMENT FEE . a ❑ Surcharge F E ❑ Other FEE <br />INSPECTOR # r C PERMIT VALID O t0 3 ❑ Food Handler <br />❑ Check# �AmOUNTPAID Date 9 2 INVOICE# ��1I <br />48-02-034 �J. /// <br />1/23/13 �y 1362-1 / � <br />