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Apr 072202:50p Century 21 M&M &Assoc. Apt 062202:43p Century 21 M&M &Assoc. 209-334-2550 209-334-2550 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTI MASTERFILE RECORD INFORMATION FORM p.2 p.3 PAYMENT RECEIVED V1 Now EH Program at Existing Facility i Cew EH Program and /New Facility APR 0 7 2022 FacilityID _ (� 27L b / ` _ 1. __ Program Record ID g" j(� y.%r SAN JO Facility Address ihl� �� k .5 GT[ v C 46"' f ENVIRONfvNENTA�Ty —r- D S HEALTH DEp (Please check the appropriate description and specify sem, number of units and pertinentinformation-) DEPARTMENT FOOD PROGRAM (1600) ❑ Restaurant: Seadng Capacity_ Square Footage Food Handlers Course rogutred: Yes ❑ No ❑ ❑Commissary ❑ Dry storageenly fl with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market ---Square footage ❑ w,rPdeat Market only ❑ Multiple Depannnords ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle --Make-__._ Vehicle Type Color Recistration 1F Licensees SBdter# ❑ Mobile Food Prep Unit --Make Vehir-le Type Color - Regist ation # Licenso # .''ticker n .,_ ❑ Temporary Food Facil Ry --Dates of operallon from :o ❑ Ice Plant 0 Produce Stand Cl Special Event ---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B pairy ❑Milk Dispenser -Number of Coniai.�ers in AOuL-i-Head Unit _ CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 9 Facility ❑ Hazardous Waste Generator (2200) -------->-Tons Generated Pee Year ❑ Tiered Permitting Facility ------> ❑ CA (2232; ❑ CE (229$ 2234, 2235, 2237) ❑ PBR ("2231) ❑ P9R HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs,�__ -_ ❑ Underground Storage Tank Program (UST) (2300) Use UST A and forms ❑ Other COPA Progran) HOUSgJG PROGRAM (2400) ❑ HotellMotet---Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee HousinglLabor Camp Application Form SITE MITIGATION %29001 UNDERGROUND INJECTION CONTROL (3000 ❑ Environmental Assessment ❑ UST -CAP Site ❑ Looal HW Cleanup Site ID, NPUSEP Cleanup Site ❑ UIC site ❑ Abandoned HW Site LT non-NPUSEP Cleanup Site ❑ RVVQCH Cleanup Site L Water Quality Remedlallon Site RECREATIONAL HEALTH PROGRAM (3600) Number or Pools!Spas at Facllitl _ CJ Pool ❑Spa El Out of Service Pool/Spa ❑Natura l t3atlting Area VECTOR CONTROL PROGRAM (4orim ❑ Poultry Farm-------plaximtar number of birds ❑ Kennel TAI 01 BODY PIERCING- PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Rog (41 10) ❑ Mechanical DSPS Notification (4115) Y^Body Art Facility -Single Use (4120) El Body Art Faci€ity-Sterilization(4121) ❑ Body AH Temp Event Co-ord 14130) ❑Body Art -Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM (4200) Q Pamper VehlcleRegislrabon i? License# Capacity VehicleN ❑Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ---Number of Units ._ stlLID WASTE PRQGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ AglCannery Waste Site ❑ SludgefAsh Site ❑ Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility D CIA Landfill Site ❑ Refuse Vehicles (4 or Units) ❑ Dumpslers> 20 cu yd suonas) ❑ FarmlRonch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator Q Limited Hauler 0 Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11- 60 ❑ > 60 generators PUBLIO WATER SYSTEM PROGRAM (4600) Use f W$ EHD 4e-02-003 Blue AppllcaNOn Form P griCYNDTIFICATI FORT IsFACILI NDfoRPROGRAM CONTACT PERS t Day P^2(Mt-sDi-laT-I�t Nignl Pir PROGRAM ELEMENT_ N /a? D _ FEE _)) /�. _ ❑ A EE ❑ Other FEE T INSPECTOR# 9 3 G _ PURMFTVALIe 2Z El Food Handler ❑ CheckV �,b.,,_ AMOUNTPA)D D - INVOIGE9 III Cash R`vonftom AGCOUar19GOFFIDate -- -- - - _ - - -- TZ IF <s-On^-eSq MASTERNIF EC RDINFORMATOIJPINK 12yli� �`f7gL%s