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SAN J.OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility New EH Program and New Facility <br />Program Record ID PRZ),S11113 i — <br />Facility Facility Address —730 S. AY/1i ,Cit6e-tpt4CA- qrs- <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage II Mobile Food Vehicle --Make <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />El Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from to DCFOOADB <br />Facility ID 4 6o2.7 <br />Square Footage <br />0 with Food Preparation <br />El w/Meat Market only <br />Vehicle Type <br />License # <br />Vehicle Type <br />License # Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />Food Handlers Course required: YES 0 No El <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 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 />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) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) El PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />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 Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPLJSEP Cleanup Site El RWQCB Cleanup Site CI Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 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-Wwt9,EW 414120) <br />0 Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) 0 Body Art-Temp EgRillile Tility (4131) <br />LIQUID WASTE PROGRAM (4200) RECEIVED <br />Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number MARts1 3 2023 <br />uN SOLID WASTE PROGRAM (4400) SAN JOAQUIN CO TY <br />laramtulaihROTAP 0 Landfill 0 Transfer Station El Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility CI Process/Recycle Facility ftletiOi UWATIMR431- <br />Refuse Vehicles (# of Units) El Dumpsters >20 cu yd (# of Units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator CI Small Generator El Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 El > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />VCONTACT PERSON Vmr4et.v.t pc,4 ,,y) a. Day Ph -91:1 7--C7 e ichqNight Ph Thrt 3 LeA <br />PROGRAM EL7ENT FEE ,tt 0 Surchqrge 0 Other FEE <br />INSPECTOR # PERMIT VALID .f1-3 c3.1=> 3 to tXt 3 0 Food Handler <br />Check # V AMOUNT PAID if ?,1- — Date /3 ?t ,A3, INvoicE # 3 85/8 <br />Date LYN ,23 Cash REVIEWED BY ACCOUNTING OFFICE <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />1/23/13 f . art 1.40,_„&___