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0 Surchar <br />to 77 <br />Date <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility Address Pc\ ‘-)\C., PDX, \NNart-C.c-0.. C13r L. ?)-5y <br />• <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />CI Restaurant: Seating Capacity Square Footage <br />Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />Mobile Food Vehicle --Make <br />Registration # <br />CI Mobile Food Prep Unit-- Make <br />Registration # <br />Temporary Food Facility --Dates of operation from to <br />Special Event---Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />CI Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />New EH Program at Existing Facyilit <br />Facility ID P141712 021-S10 <br />ew EH Program and New Facility <br />Program Record ID FLO 5-1( S,z_q Lf <br />24 <br />El CFO B <br />Ay <br />‘-NT ceiv&i ,„ <br />1•=1J FEB 28 2023 <br />sky JoA QU/N CO Ha4/7410A,r UwAir, Nry <br />uePARTAll.tivr <br />Food Handlers Course required: YES CI No CI <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Vehicle Type Color <br />License # Sticker # <br />Vehicle Type Color <br />License # Sticker # <br />CI lc Plant 0 Produce Stand <br />2C CONTACT PERSON ( \ ay\ ,a1 <br />PROGRAM ELEMENT 1 6, 6 5- FEE <br />INSPECTOR # R1 k ilky PERMIT VALI <br />Check # i AMOUNT PAID <br />Cash REVIEWED BY <br />4 -02-034 <br />1 23/13 <br />Hazardous Materials Business Plan (1900) <br />El CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) CI CE (2233, 2234, 2235, 2237) CI PBR (2231) 0 PBR HHW (2236) <br />CI Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />CI 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 Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment CI UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility CI Pool CI Spa <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) CI Mechanical DSPS 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 />Pumper VehicleRegistration # License # <br />CI Pumper Yard 0 Package Treatment Plant CI Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill CI Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (# of Units) 0 Dumpsters > 20 CU yd (# of Units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator CI Limited Hauler <br />CI Transfer Station CI Veterinary Clinic CI Common Storage Facility 0 2 - 10 CI 11 - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EmERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />)8'6.0o <br />Number of chemicals: <br />4 M STERFILE R COR INFORMATION PINK <br />ACCOUNTING OFFICE <br />op <br /> Capacity Vehicle # <br />Day Ph(2.1-4,92-sA —149012, Night Ph <br />0 Out of Service Pool/Spa <br />0 Other FEE <br />El Food Hamill <br />INVOICE # <br />Date <br />Natural Bathing Area <br />0 Kennel <br />--1(‘;00