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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Proqram at Existing Facilitv ❑New EH Program and New Facilitv PAYMENT RECEIVED Facility ID /'1IO7ZlvKiZ Program Record ID i S. t 4f7 aD II JAN 2 5 2022 Facility Address 730 5. CAji 'Pj2i'bl n s� Q k4 -t C1c57-D 3 (Please check the appropriate description and specify size number of units and pertinent information.) SAN JOAQUIN COUNTY ENVIRONMENTAL FOOD PROGRAM (1600) HEALTH DEPARTMENT ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No LI ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ )Retail Market—Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only JIbC Mobile Food Vehicle --Make Vehicle Type Color Registration # License # Sticker # ❑ Mobile Food Prep Unit– Make Vehicle Type Color Registration # License # Sticker # ❑ Temporary Food Facility –Dates of operation from to ❑ Ice Plant ❑ Produce Stand ❑ Special Event ---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B 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 ❑ Hazardous Waste Generator (2200)– -------- >-Tons Generated Per Year ❑ Tiered Permitting Facility ------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program ❑ Program 3 Facility ❑ PBR (223 1) ❑ PBR HHW (2236) HOUSING PROGRAM (2400) ❑ Hotel/Motel —Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION 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 Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -----Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (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 Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (413 1) LIQUID WASTE PROGRAM (4200) ❑ Pumper VehicleRegistration # License # Capacity Vehicle # ❑ Package Treatment Plant ❑ Chemical Toilets —Number of Units ❑ Pumper Yard SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Waste Tire Facility ❑ Compost Facility ❑ Refuse Vehicles (#of units) ❑ Ag/Cannery Waste Site ❑ Process/Recycle Facility ❑ Dumpsters > 20 cu yd (# of units) ❑ Sludge/Ash Site ❑ CIA Landfill Site ❑ 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 ❑ 11 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form ^_ _a I�O EMERGENCY NOTIFICATION FORTHIS FAGILI I Y AND/OR PKUGKAM CONTACT PERSON Off& e rtao 'I Day Ph 2 Night Ph 2C0- 2%A4 • (0(eq PROGRAM ELEMENT FEE I ❑ Surchar e FEE ❑ Other FEE INSPECTOR#-PERMITVALID 22- to El Food Handler ❑ Check# .5�- AMrO�tU�NTPAID Date INVOICE# 8 ❑Cash REVIEWED BY 1 /1 - ACCOUNTING OFFICE Date v ? 2 1/23/13JV I I 1123113