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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PAYMEIV-r MASTERFILE RECORD INFORMATION FORM ftCEiVED ❑ New EH Program acility glNew EH Program and New Facility SEP 1 Facility ID2 Program Record ID ?R05 719 8 2021 SARI JCAQUIN COUNTY ress cA IS-351 ON MEN (Peaselt�c�kLtdhedappropriate des\ript on and specify s e, numb�erLof units a pertinent reformation.) H��R EPARTM FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs,B' No ❑ Er Commissary ❑ Dry storage only Prwith 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# 10-Mobile Food Prep Unit--Make V1RMrclL- Vehicle Type SPCM Color 'PtOY- Registration# License# LI "4 ft I 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: ❑ 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 ❑ Underground Storage Tank Program (UST)(2300)Use UST and B forms ❑ Other CUPA Program 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 ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP 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 Coord (4130) ❑ Body Art-Temp Event Mobile 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 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 112-10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form nr�,,,,-�� EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM * CONTACT PERSON 1�AI`-Gt" tA0.1AfI- Day Ph (SNJ)6cD-\2H O Night Ph PROGRAM ELEMENT `105 FEE 2 EISurcharg FE ,,�7 11 Other FEE INSPECTOR# _ b` PERMITVALID -7� t0 j ❑ Food Handier ❑ Check# AMOUNT PAID •0D Date 2 y- INVOICE# J[ ZD ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 1123/13 73