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JAN JUAWL11114 L UUN I T CNV IKUNMCN i AL r1CAL t r7 UCr-Am 1 MCN 1 MASTERFILE RECORD INFORMATION FORM ®SNeW EH Proaram at Existinq Facility ®New EH Program and New Facility Record ID PAYMENT RECEIVED Facility Address \LAII Y, -�\Af/_Cy1 i.-r_�l\-L �U I T�- 1% MAY 2 4 2022 (Please check the appropriate description and specify size, number of units and pertinent information.) SAN JOAQUIN COUNTY ENVIRONMENTAL FOOD PROGRAM (1600), HEALTH DEPARTMEW 11 Restaurant: Seating Capacity Square Footage �V 00 Food Handlers Course required: YES 11 NO LY ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units gRetail Market—Square footage UDO = T ❑ with Meat Market only ❑ Multiple Departments[] Prepackaged Goods Only ❑ Mobile Food Vehicle–Make Vehicle Type Color Registration If License # Sticker # ❑ Mobile Food Prep Unit Make Vehicle Type Color Registration # License # Sticker # ❑ Temporary Food Facility –Dates of operation from to ❑ Ice Plant ❑ Special Event Dates of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit CUPA ❑ State Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator ---------Tons Generated Per Year ❑ Recycle/Exempt System (2299) ❑ CRT Offsite Handlers (2218) ------❑ Silver Only (2222) ❑ Appliance Recyclers (2217) Tiered Permitting Facility ------ --------- –❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) ❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use USTA and B forms HOUSING PROGRAM (2400) ❑ Hotel/Motel—Number of Units ❑ Jail or Exempt Institution —Number of Units Employee Housing (2700) Use Employee Housing/Labor Cama 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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm --Maximum number of birds _ ❑ Spa TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (4121) ❑ Body Piercing (4120) LIQUID WASTE PROGRAM (4200) ❑ Out of Service Pool/Spa ❑ Natural Bathing Area ❑ Kennel ❑ Permanent Cosmetics (4122) ❑ Pumper VehicleRegistration # 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 ❑ ProcessfRecycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd (# of Units) ❑ 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 CONTACTPERSON _01 Ph PROGRAM ELEMENT6 i5 FEE r �Q ❑ Surcha e F E ❑ Other FEE INSPECTOR# PERMIT VALID 2 .ZZ to 5 3r ❑ Food Handier 11Check #_ AMOUNT PAID 46 :2 -SO- OD Date S ZZ– INVOICE # ❑ Cash REVIEWED BY ACCOUNTINGOFFICE /,�� Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 691/ -k /`/� 125,367