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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />rACD •Z7 cY/4%v7. <br />14N 6y 2023 <br />5,4 N jo4 <br />/4\PR2/1//117 couN <br />r2k,v 7.2-'z <br />MASTERFILE RECORD INFORMATION FORM <br />„Ei New EH Program at Existing Facility <br />1 Facility ID .T-- <br />Facility Address /(7 'IC)/ fifi--r —/6"/ Rd L.19 /11,-- , C— <br />il)02-71-13 Pror9ram Record ID ?R-D .74-.-tr,-Z7313 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />gitestaurant: Seating Capacity Square Footage <br />Food Handlers Course required: YES 0 No 0 ir Commissary 0 Dry storage only 0 with Food Preparation <br />OVending Machines Number of Units <br />Retail Market----Square footage El w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />El 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 El Ice Plant CI Produce Stand <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy CI Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals. <br />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) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />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 />0 Environmental Assessment CI UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site El non-NPL/SEP Cleanup Site CI RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool CI Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 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 />LI04.11D WASTE PROGRAM (4200) / 'Limper Vehicle Registration #License A I Capacity _ff -f 4 Vehicle #_ <br />Pumper Yard IL Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site <br />CI Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (tt or units) 0 Dumpsters > 20 cu yd (tt or units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care CI Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 -60 0 >60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application Form <br />ONew EH Program and New Facility <br />CONTACT PERSON <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />Day Ph " Night Ph 1---t*. 7/2 <br />PROGRAM ELEMENT 168Q FEE 30 0 Surchar e F E 0 Other FEE <br /> <br />INSPECTOR # 4589 <br />Check ll <br /> PERMIT VALID 2-3 <br />AMOUNT PAID <br /> DO <br />to 1 31 Z 0 Food Handler <br />Date INVOICE # 3773?