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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ew EH Program and New Facility Facilit ID �� Program Record ID 0� [ 7–.�v Facility Address 1 1 f I) \tjy 0�E1n;SAV6. InvT D CA, G4 95 3 ' - (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) restaurant: Seating Capacity fes_ Square Footage q0Q Food Handlers Course required: YESA No ❑ ❑ 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 ❑ 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---Dales 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: ❑ CalARP Program ❑ Program 1 Facility ❑ 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 PAYMENT ❑ Underground Storage Tank Program (UST)(2300)Use UST A and B forms RECEIVED ❑ Other CUPA Program MAR 0 9 2022 HOUSING PROGRAM (2400) ❑ Hotel/Motel---Number of Units ❑ Jail or Exempt Institution ----Number of Units—J04ou NCO ly Employee Housing(2700) Use Employee Housing/Labor Camp Application Form Ni n�rN ocvna*n�eNr 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 El Water Quality Remediajion Site RECREATIONAL HEALTH PROGRAM (3600) PA MEN- Number of Pools/Spas at Facility 11 Pool 11 spa ❑ Out of Service Pool/Spa C(x A2thing Area VECTOR CONTROL PROGRAM(4000) ^ 11 Poultry Poultry Farm-------Maximum number of birds j`K L TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ;,N'o oumr °"TP tN HONNIEN ' ❑ Body Art Practitioner Reg (4110) 13 Mechanical DSPS Notification (4115) 1:1 Body Art Facility-Si 46 .N1 120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Coord(4130) ❑ Body Art-Temp Eve TATTOO. Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# 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 (#of Units) ❑ Dumpsters>20 cu yd (#of Upas) ❑ 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 - 10 011 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON 1 N Day Ph 5/0 Night Ph PROGRAM ELEMENT /,/, 2 3 FEE ❑ 5urcinrge�EE ZEl Food FEE INSPECTOR# PERMITVALID oo3 27i t0 3l o 3 Food Handler T 1:1Check# AMOUNT PAID J 5d Date ZfJ INVOICE# 11 Cash REVIEWED BY ACCOUNTING OFFICE T�TlDate` x- 48-02-034lY' I/ I ASTERFILE R CORD INFORMATION PINK 1123/13 l lL O 1 T) � �� Z 2--