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CI New EH Program at Existing Facility New EH Program and New Facility <br />Facility ID 1t-74 oo 2 Program Record ID -PRDS-q-g2_24 <br /> <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />PROGRAM ELEMENT -3 (2 ( FEE <br />INSPECTOR # <br />Check # <br />CI Cash <br />0 Surchar <br />to <br />Date <br />ACCOUNTING OFFICE <br />0 Food Handler <br />INvoicE# <br />Date <br />48-02-034 <br />1/23/13 <br />MASTERFILE RECORD INFORMATION PINK <br />&12- <br />23 <br />CI Other FEE <br />PERMIT VALID <br />AMOUNT PAID <br />REVIEWED BY <br />Facility Address 111 ev. <br />nate description and specify size, number of units and pertinent information.) <br />PAYMENT <br />RECEIVED <br />JAN 2 7 2023 <br />SAN JO COUNTY S <br />N <br />AV <br />ENTLALENT (4AL4414TH DEAR (Please check the appro <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />El Commissary 0 Dry storage only <br />Retail Market----Square footage <br />CI Mobile Food Vehicle --Make <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />Square Footage <br />CI with Food Preparation <br />w/Meat Market only <br />Vehicle Type <br />License # <br />Food Handlers Course required: YES 0 No 0 <br />ElVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Sticker # <br />Vehicle Type <br />License # <br />Sticker # <br />Color <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant CI Produce Stand <br />CI Special Event---Dates of operation from to 0 CFO 0 A 0 B <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 />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 />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />El Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units CI 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 CI Local HW Cleanup Site El NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site El 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 Pool 0 Spa CI Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br /> <br />0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) <br />CI Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # Capacity Vehicle # <br />CI Pumper Yard 0 Package Treatment Plant <br /> CI Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill CI Transfer Station El Ag/Cannery Waste Site 0 Sludge/Ash Site <br />CI Waste Tire Facility CI Compost Facility 0 Process/Recycle Facility CI CIA Landfill Site <br />Refuse Vehicles (II of Units) El Dumpsters > 20 Cu yd (# of Units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care CI Acute Care 0 Skilled Nursing <br />CI Transfer Station CI Veterinary Clinic 0 Common Storage Facility 0 2 - 10 CI 11 -60 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FA I TY AND/OR PROGRAM <br />CONTACT PERSO Mdak+ Day Ph - 95-S*-455-3.§1ght <br />0 Large Generator 0 Small Generator 0 Limited Hauler <br />El > 60 generators