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-- R q YMF FSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT JA�C'pw'7 MASTERFILE RECORD INFORMATION FORM A' ---- �I'tr ?3 ❑New EH Pro ram at Existing Facility ❑New EH Program and New Faeilit S,4/v,)( 2023 Facilit ID r ,'Z Sd 2 Pro ram Record ID $�.z- q NV/AQU�'V CO x Facility Address 4�40 W a acv PYQ j MAKT ECA, Cf\—°15�33�ND �ND pMFTq NTy (Please check the appropriate description and specify size,number of units and pertinent information► ARTMFNT �C FOOD PROGRAM(1600) • I�Restaurant Seating Capacity Square Footage Food Handlers Course required: YES❑ No ❑ ❑Commissary ❑Dry storage only ❑with Food Preparation ❑Vending Machines slumber of Units ❑Retail Market---Square footage ❑w/Meat Market only ❑Multiple Departments❑Prepackaged Goods Only ❑Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# ❑Temporary Food Facility—Dates of operation from to _ ❑ Ice Plant❑ Produce Stand ❑Special Event—Dates of operation from to [:]CFO ❑A❑ B r DAIRY PROGRAM(2000) ❑Grade A Dairy ❑Grade B Dairy ❑Milk Dispenser-Number of Containers in Multi-Head Unit— COPA ❑Hazardous Materials Business Plan(1900) Number of chemicals ❑CalARP Program ❑Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑Hazardous Waste Generator(2200)-------->-Tons Generated Per Year ❑Tiered Permitting Facility------> ❑CA(2232) ❑CE(2233,2234,2235,2237) ❑PBR(223 1) ❑ PBR HHW(2236) ❑Aboveground Storage Tank Facility(AST)(2800) Number of ASTs ❑Underground Storage Tank Program(UST)(2300)Use UST A and B forms ❑Other CUPA Program HOUSING PROGRAM(2400) ❑Hotel/Motel-=—Number of Units ❑Jail or Exempt Institution--Number of Units Employee Housing(2700)Use Employee Housing/Labor Camp Application Form SITE MITIGATION(,2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑Abandoned HW Site ❑non-NPUSEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Nurncer of Fcols'Spas at Facility ❑Pool ❑Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑Poultry Farm--Nlaximum number of birds ❑ Kennel TATTOO.BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) ❑Body Art Practitioner Reg(4110) ❑Mechanical DSPS Notification(4115) ❑ Body Art Facility-Single Use(4120) ❑Body Art Facility-Sterilization(4121) ❑Body Art Temp Event Co-ord(4130) ❑ Body Art-Temp Event Mobile Facility(413 1) LIQUID WASTE PROGRAM(4200) ❑Pumper VehicleRegistration# License# Capacity Vehicle# ❑Pumper Yard ❑Package Treatment Plant ❑Chemical Toilets—Number of Units SOLID WASTE PROGRAM(4400) ❑Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑Waste Tire Facility ❑Compost Facility ❑Process/Recycle Facility ❑CIA Landfill Site ❑Refuse Vehicles(k of u-.,ui ❑ Dumpsters>20 cu yd r-of Un is ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑Primary Care ❑Acute Care ❑ Skilled Nursing ❑ Large Generator ❑Small Generator ❑ Limited Hauler ❑Transfer Station ❑Veterinary Clinic ❑Common Storage Facility ❑2-10 ❑ 11 -60 ❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02.003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANWOR PROGRAM 70 CONTACT PERSON ' Day Ph5'IO-750 13* Night Ph!;I-» PROGRAM ELEMENTS G, 2 3 FEE ❑Surcfjrge EE ❑Other FEE INSPECTOR#-� PERMIT VALID ) l0 12 ❑Food Handier ❑Chco p AMOUNT PAID41� t✓•�� Date 23 INVOICE# ❑Cash RiviEVVED BY 69 AccOUNTING OFFICE Date 4P,02-034 AIASTERFRE REC15RD JORMATION PINK 1�?yt3 I SS 2D 2-$