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PROGRAM ELEMENT \\Oct 5 FEE \ Sk0 0 Surcharge FEE <br />INSPECTOR # t- (.\‘(10\ (PERMIT VALIIkit:) • VS to ko • I 0. '2- <br />Check # CkS AMOUNT PAID (7 /56 • 00 Date <br />Cash REVIEWED BY ACCOUNTING OFFICE <br />Other FEE <br />Food Handler <br />INVOICE # <br />Date 57/ 3),_- 3 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 <br />MASTERFILE RECORD INFORMATION FORM <br />New EH P ,-:am at Existing Facility (=New EH Program and New Facility <br />Facility ID -Ft) 00Z7ko‘? Program Record ID FoeciSLI-Sq-±7 <br />,,PAVIVIENr <br />T CE.1 VED <br />MAY 1 8 2023 t sAN jo 4 couvr,, ,. rAL <br />i HEALTH <br />ENviRoNmetv <br /> DEpARTmeNT Facility Address -25-A-e /f' ZI'27 4E, a)1 .9j-3 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market—Square footage <br />(2..Mobile Food Vehicle -Make <br />Registration # <br />Mobile Food Prep Unit- Make <br />Registration # <br />Temporary Food Facility -Dates of operation from <br />er Special Event—Dates of operation from -*/D- 201-3 <br />Square Footage Food Handlers Course required: YES 0 No 0 <br />0 with Food Preparation I:Vending Machines Number of Units <br />0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Vehicle Type <br />License # <br />Vehicle Type Color <br />License # Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />to - CI CFO 0A0B <br /> Color <br />Sticker # <br />DAIRY PROGRAM (2000) <br />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 />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 />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 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 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 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 />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # <br />0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets —Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (tt of Units) 0 Dumpsters > 20 cu yd (tt or 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 />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON <br />E ERGEN Y N TIFICATION FOR THIS FACILITY AND/OR PROGRAM 424rAe A_ Day Ph 4/24/7: OP'-913rNight Ph Ala V- 3-f--6,49c. <br />48-02-034 MASTERFILE RECORDINFORMATION PINK <br />1/23/13 <br />// 3()7 <br />MD 247 77 gL5- <br />Scanned with CamScanner <br />0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />Capacity Vehicle # <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />11 - 60 0 > 60 generators