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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at ExistingFacility Whew EH Program and New Fact It Facts ID Q f,1 /yProgram Record ID 1224-7417 Facility Address 73]T OTc4on AV- Sets., t:F1 95204 (Please check the appropriate description and specify size number of units and pertinent information.) 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 Units _ ❑ Retail Market—Square footage ❑ w/Mast Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color _ Registration# License# Sticker# ❑ Mobile Food Prop Unit–Make Vehicle Type Color Registration# License# __ Sticker#_ ❑ Temporary Food Facility–Dates of operation from to ❑p�Ice Plant❑ Produce Stand [IW Special Event—Dates of operation from to 5j CFO A❑ B DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit . COPA ❑ Hazardous Materials Business Plan(1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facifky ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)-->-Tons Generated Per Year ❑ 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 UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ HotellMotet--Number of Units El 1211 or Fxcimpt Inatitution--Numbor of Units Employee Housing(2700)Use Employee HousinalLabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site�V❑ UIC site ❑ Abandoned HW Site LJfion-NPUSEP Cleanup Site ❑ RWQCB Cleanup site 11 Water Quallyiwlas lte RECREATIONAL HEALTH PROGRAM(3600) RECEIVED Number of PooWSpas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service PooYSpa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4D0o) JAN 2 0 2022 ❑ Poultry Farm—Maximum number of birds ❑Kennel TATTOO.BODY PIERCING.PERMANENT COSMETIC PROGRAM(4 100) SAN JOAQUIN COUNTY ❑ Bed Art Practitioner R 4110 ❑ Mechanical DSPS Notification 4115) ❑ Body Art Facili ENVIRONM�E��t`�,T�"E Y e9( ) ( Y LY-RLMLI�I�BE�AfFFU_NT ❑ Body Art Facility-Sterilization(412 1) ❑ Body Art Temp Event Coord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper VehicleRegiShation# Llcanse# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ AglCannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#a u1 ) ❑ Dumpsters>20 cu yd(#or un�) ❑ 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 1:111 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46.02-00)Blue Application Form EMERcY NOTIFICATION FOR Tws FACILrTY ANdoia PROGRAM CONTACTPERSOH fi ►/I f e Day Ph 20 -4lL- 5`l Night Ph 2"-4_71.5387 PROGRAM ELEMENT U aiqFEEDS urche FEE ❑ Other FEE INSPECTOR# �{ PeRMrt VALID I Z to 1 3 L1Food Handler ❑ Check# AMouNTPAID tate ! 2d Z INVOICE# 3 ❑ Cash REVIEWED BY k1l ICE Date 4"2-0M MASTENFILE FORMATION PINK 1123f13 coof 1376378SG I