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PAYMENT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED <br />MASTERFILE RECORD INFORMATION FORM _I MAY 3 O 2022 <br />❑ New EH Program at ExistingFacilityWNew EH Program and New Facili SAN JOA <br />FacilityID 002 q Program Record ID ENVIRONMENTAL <br />Facility Address � �= LS (A(`TC- ( C!� H�A T6prTMENT <br />(Please check the appropriate description and specify sue, number of units and pertinent information.) .S (Q T - <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity y Square Footage Food Handlers Course required: Yes ❑ No 0( <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />Nf Retail Market --Square footage 11100 ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle —Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Mobile Food Prep Unit— Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Temporary Food Facility —Dates of operation from to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event --Dates of operation from to ❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dalry ❑ 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 Emn/oyes Housinp&abor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWOCB Cleanup Site ❑ Water quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service PoollSpa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm --Maximum number of birds ❑ 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 # License # Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets —Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (#o(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 ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Apalication Form <br />CONTACT PERSON (Ii- <br />L j 4117)u- <br />Day Ph 20�- (c77- LOJy <br />Night Ph <br />ELEMENT�� FEE <br />-� O ❑ SurchargFE <br />❑ Other FEE <br />#� PERMITVALID <br />.5 ,3(j .ZZ IO J 31 <br />❑Food Handler <br />AMOUNTPAI <br />E <br />d Date S 3 Z <br />INVOICE# <br />REVIEWED BY " <br />ACCOUNTING OFFICELILL <br />Date L Z <br />45-02-034 <br />MASTERFILE RECORD INFORMATION PINK <br />1123/13 <br />L f <br />-' 13- 7S77� <br />