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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Prooram at Existing Facility ❑New EH Program and New Facility Facility ID C�b Z_/ /1 Prograrn Record ID KU5`t6 Facility Address _ -�3 _- __ G///� S-ir{'F j 4,-)W, ;Please check the appropriate description and specify size number of units and pertinem information ) FOOD PROGRAM (1600) PAYMENT RECEIVED DEC 19 2022 SAN JOAQUIN COUNTY G HEEI IbYDE4%13 (e. ❑ Restaurant Seating Capacity__ Square Footage Food Handlers Course required: YE�No ❑ ,,tj )'Age Commissary 2' U storage only 0<ih Food Preparation ❑Vending Machines Number of Units _ _ J❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle –Make_ Vehicle Type - _ Color Registration # . _ License # _ _ __. Sucker lt ❑ 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—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 COPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals. ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator (2200) ---------- >-Trans 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 A and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ HoteliMotel ---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 Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) LIOUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration # _. License # _. _,. Capacity Vehicle If _ - ❑ 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 (x of upas) ❑ Dumpsters > 20 cu yd i# til umsi ❑ 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 CONTACT PERSON_ .1/J-�i- _ _1�,tjj0jj Day Ph :X_q LLJ_Z ,'Dl Night Ph�l%_ PROGRAM ELEMENT FEE FEE ❑ Surchar e F E ❑ Other FEE INSPECTOR # 12 r PERMIT VALID .2to ._., 1 _3;( 2.3 ❑Food Handler ❑ Check # -_ AMouNT PAID 237, 0 Date ( 142_:;–:_— INVOICE # 37 067 ❑ Cash REVIEWED BY ACCOUNTING OFFICE Dale 48 e2-034 MASTERFILE RECORD INFORMATION PINK 12113 J n /T� I' 7 2D