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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 Food Handler <br />7-2-- INVOICE # <br />Date <br />4 04, <br />Rer , cN <br />LIED <br />NOV <br />47 <br /> <br />Facility Address .171051.elfact,_ LAtt,gLivi ofc:30 LTH0EgewirAL TY <br />IMENT <br />quired: YES 0 NO 0 <br />ber of Units _ <br />Prepackaged Goods Only <br />Vehicle Type Color _ <br />Sucker' - <br />Vehicle Type <br />License <br />Color <br />license # StickCerflor <br />to 0 Ice Plant 0 Produce Stand <br />.CFO DAUB <br />0 New EH Program at Existing Facility XNew EH PLpram and New Facility SA <br />Facility ID PACC0.74±11-3 Program Record ID P-094- <br />1 5 2022 <br />(Please check the appropriate description and specify aim, number of units and pertinent information) <br />FOOD PROGRAM (1600) <br />0 Restaurant Seating Capacity Square Footage _ _ _ _ Food Handlers Course re <br />0 Commissary 0 Dry storage only 0 with Food Preparation °Vending Machines Num <br />0 Retail Market----Square footage 0 wiMeat Market only 0 Multiple Departments 0 <br />0 Mobile Food Vehicle --Make <br />Registration # <br />0 Mobile Food Prep Unit-- Make <br />Registration # <br />0 Temporary Food Facility --Dates of operation from <br />0 Special Event--Dates of operation from to <br />‘4( skve 2 ock ok c MAT.TERFILL R ORD ORMADON PiNh <br />48 02 034 <br />1,7313 <br />DAIRY PROGRAM (2000) <br />0 Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Mum-Head Unit _ <br />CUPA <br />0 Hazardous Materials Business Plan (1900) Number of chemicals <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />0 Hazardous Waste Generator (2200) > -Tons Generated Per Year <br />0 Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234. 2235. 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />0 Hotel/Motel Number of Units 0 Jail or Exempt Institution ---Number of Units <br />Employee Housing (2700) Use Employee Housino/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />0 Environmental Assessment 0 UST-CAP Site 0 Local 11W Cleanup Site 0 NPLJSEP Cleanup Site 0 UIC Site <br />0 Abandoned HW Site 0 non-NPUSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />1:1 Poultry Farm Maximum number ol birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />El Body Art Practitioner Reg (4110) 0 Mechanical OSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />0 Pumper VehicleRegistration V License V Capacity Vehicle <br />0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number ol Units <br />SOLID WASTE PROGRAM (4400) <br />0 Landfill 0 Transfer Station <br />0 Waste Tire Facility 0 Compost Facility <br />0 Refuse Vehicles (a ol units, <br />MEDICAL WASTE PROGRAM (4500) <br />O Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 0 > 60 generators <br />Poem WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application Form <br />EMERGENCY NOnFICA.TIONFOR THIS FACILITY ANWOR PROGRAM <br />CONTACT PERSON V.-( 5 pis. Day Ph R43117h <br />PROGRAM ELEMENT FEE Ye) - o SUrcharge FEE 1:1 Other FEE <br />INSPECTOR (\Ina( eSPERmiT Vain& I to <br />0 Check* VI AMOUNT PAIDF )5Zg•C:10 Date <br />0 Cash REVIEV/ED BY ACCOUNTING OFFICE <br />0 Ag/Cannery Waste Site 0 Sludge/Ash Site <br />O Process/Recycle Facility 0 CIA Landfill Site <br />0 Dumpsters > 20 cu yd at units) ID Farm/Ranch Cleanup Site <br />-4fr 1522-17‘50