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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility ?New EH Program and New Facility <br />Program Record ID <br />/Facility Address X clq (A), 6ri IWO Mpuri-f-ain itog(j c.3 7 I <br />(Please check the appropriate description and specify sLizsj number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity Square Footage <br /> <br />Food Handlers Course required: YES 0 No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation <br />0Vending Machines Number of Units <br />Retail Market—Square footage 0 with Meat Market only 0 Multiple Departments0 Prepackaged Goods Only <br />Mobile Food Vehicle -Make Vehicle Type Color <br />Registration # License # Sticker # <br />Mobile Food Prep Unit Make Vehicle Type <br />Registration # License # <br />Temporary Food Facility -Dates of operation from to <br />Facility ID rkr-t) Z11, <br />Color <br />Sticker # <br />0 Ice Plant <br />Special Event Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy <br />CUPA 0 State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />Hazardous Waste Generator—Tons Generated Per Year <br />CRT Offsite Handlers (2218) 0 Silver Only (2222) <br />Tiered Permitting Facility 0 Conditionally Authorized (CA) <br />0 Permit-By-Rule Fixed Unit <br />0 Produce Stand <br />Recycle/Exempt System (2299) <br />0 Appliance Recyclers (2217) <br />Conditionally Exempt (CE) <br />Permit-By-Rule Household Hazardous Waste <br />0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <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 />0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPLJSEP 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 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 />Tattooing (4121) 0 Body Piercing (4120) 0 Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets —Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 -10 0 11 -60 ,43„,h0 gen <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Nit 4lipleanup Site <br />MEN <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (# of Unds) <br />0 Small Generator 1:§Wrrie <br />rs <br />EM GENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM J0/4 Q <br />iipAEN11,2 U/A/ Cno <br />.7.-CONTACT PERSON PC \ C\-GL V d\-QC-A Pi Day Ph bloc% • 2 4 Li - (8, 10 Ittight Ph ---1/..7 n74 -Abtk• --ONty n— AqA , <br />0 Surcharge FEE 0 Other FEE <br />INSPECTOR # L:\ (q.\ 0V e5 PERMIT VALID LA • 'o2.3 to LA• --5'0.-21/4-1 0 Food Handler <br />Date 1-4 2 a INVOiCE # 3113L <br />i ACCOUNTING OFFICE Oil Al Date <br />115°0 2 1-1- <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form 3 SA 2023 <br />PROGRAM ELEMENT 0e8 FEE <br />I, 0 9peck # AMOUNT PAID , <br />m/cN,Aill REVIEWED BY