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7 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility ONew EH Pro ram and New Facility <br />r0400 -741-11-0 Program Record ID rgir-)643011( Facility ID <br />0 Ag/Cannery Waste Site <br />0 Process/Recycle Facility <br />0 Dumpsters > 20 cu yd (# of units) <br />Sludge/Ash Site <br />0 CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />6 -q1 FEE <br />PERMIT VALI <br />AMOUNT PAI <br />REVIEWED BY <br />0 Surcham <br />to <br />Date <br />ACCOUNTING OFFICE <br />PROGRAM ELEMENT <br />INSPECTOR # <br />0 Check <br />o Cash <br />PAYIVIENT RE CEIVED <br />NOV 1 6 2022 <br />SAN JOAQUIN COUNTY ENVIRO <br />NMENTAL HEALTH DEPARTMENT <br />Facility Address UM Maul St IC/pm, (15gletzi <br />(Please check the appropriate description and specify size, number of units and pertinent information) <br />FOOD PROGRAM (1600) <br />0 Restaurant Seating Capacity Nil\ Square Footage <br />0 Commissary 0 Dry storage only 0 with Food Preparation <br />XRetail Market---Square footage 5 50 0 w/Meat Market only <br />Mobile Food Vehicle --Make <br />Registration # <br />Color <br />Registration # License # Sticker # <br />0 Mobile Food Prep Unit-- Make Vehicle Type <br />0 Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />0 Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />Vehicle Type <br />License # <br />Food Handlers Course required: YEOZ( No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments Ei.Prepackaged Goods Only - - Color CrhOgt— <br />Sticker # <br />DAIRY PROGRAM (2000) <br />0 Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit <br /> <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 />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 />Hotel/Motel Number of Units 0 Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Point <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPUSEP Cleanup Site 0 UIC Site <br />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 0 Pool <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) 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 />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # <br />Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />0 Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles y: of units; <br />MEDICAL WASTE PROGRAM (4500) <br />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 />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Ju4arl Co i 1-e 4Ze Day Ph L-n tot/ 1L1i6 Night Ph Sa vrie, <br />Other FEE <br />Food Handler <br />INVOICE # 3 i / 7,6 <br />Date // ,gr.7 <br />0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />0 Kennel <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />48-02 034 MASTERFILE RE OR INFORMATiON PINK <br />11313