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PAYMENT j SAN JOAQUIN COUNT Y ENVIKONMtN I AL Ht:AL I M UtrAtc t Ment IVED MASTERFILE RECORD INFORMATION FORM SEP 2 g 2020 t.yuw I_H Program at Existing Facility ❑New EH Pro run and Now Facifr SAN JOAQUIN COUNTY Fazilq ID 150210 Program Record ID �— HEALTH DEENVIRONP ENTgL Facility Address 3L{LZ- W • aml�ne_Y C,� _ I,u!-�.>`- J 3tt( k�� (; 53 r lel easrl check t`ie apprc•Oriutu description and spuuly sire,number of units and Lcrtinent informabon.) i-o>D PROGRAM(1600) ❑ Restaurant, st-afing Capa:jty__ :xlunrr Footage Food Handlers Coursc required: YES ❑ No ❑ ❑ Commissary ❑ Ory storage only ❑YAM Food PreparaWn ❑Vending Machin"Number of Un1s _ ❑ Rctrif MarlKel----✓quare foolugtt ❑wFMo•jt Market only ❑ Multiprc ❑ Prcpa.kaged Gnods Only ❑ Mobile Food Vehicle Ltake Vehiclo Typic Color Repistration 1r 1.lcense ly_ _ Sti kcr# ❑ Wbilc Food Prep Unit—Make Vr:I licit- I ype __ ce-or_ Reg,siration# t'(WrA# _ SUckar t ❑ Temporary Food Facility • nates of opuiatiuri tion to _ ❑ Ice Plant❑ Produce Stand ❑ Special Even—•Irate ofoperation from to (7 CFO ❑ A❑ E 2)uRY PKQc_2NA4 (2oao) ❑ Grade A Dairy ❑ Grade B Dairy U Milk Dispenser-Number of Ccnla-.rx�(s In Multi-Head Unit CL1PA ❑ Hazardous Materials Business Plan(1900) Numbf r of&.en•.'ci's _ ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)-- • >-fnnr.Cianerated Per Year__ ❑ Tiered Permitting Facility-- 0 CA(2232) ❑ CE (2733, 22:A,2236,2237) ❑ POR(1731) ❑ PBR HII1W i'>236) ❑ Abovogroun 9 Storage Tank Facility(AST)(2800) Nurribm of AS rs _ ❑ Underground Storage Tank Prayram(UST);2"300) Usv UST A and B forms ❑ Other CUPA Program gC.:inING PROGP.AM(2400) l ❑ HotellMotcl N„tuber of knits _ ❑Jail or Exempt Institution -Number of Units _ Employer:HousiM(2700)Om- Employee HnuvinglLahor Camp Appli ai liar(Form =MITIGATION i2004y UNDI-RGROUND INJE(:1 ION CONTROL(3000) ❑ Environmenal Asseswncnt ❑ UST-CAP Site ❑ Local HW Cleanup Sito ❑ NPUSEP Cleanup Site ❑ LAC Site ❑ Abandoned 1W Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Watcr Quality Remediation Site RFCRfATIONAL HEALTH PRQGRAM(3600) NLmbcr ul Pmjle]Spas at Faclily ❑ Pool ❑ Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PH0137RAM(4000) ❑ Poultry Fann---Maximum number of birds n- Kennel TA?TOO•BODY Nit-RCING,PERMANENT cosuc IC PROGRAM (410n) 1 Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) El Body Art Facility Single Use(41,20) Body Art Facility Sterilization (4121) ❑ Body Art Temp Event Co-ord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) 1 I UID WASTC PROG"/ (420)1, L] Pumper Vehiclen^eg�straUun 9 1 rc:rnse. Gnpauty Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets---Nurnbc.-r of Unis SOLID WA�Tt-PROGRAM(4.100) C Landfill ❑ Transfer Station ❑ AglCannery Waste Site ❑ SludgelAsh Site. C Waste Tire racilrty ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site C Rcrusc Vehicles lv❑r unlsl — ❑ Oumpsters>20 cu yd ra ni urasi ❑ Farm/Ranch Cleanup Sitc MEDICAL WASTF PROGRAM(4500) C Primary Car-- ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler C Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 10 ❑ 11 -Go Cl ECJ gennrauxs PUBLIC WATER 3YSTFM PROGRAM(4600)Lhw PWS EHU 46-02-003 SIugApplication FOnrl EMFRGo,icy Norli ICAI ION F014-THIS FACILITY m4olciR PROGRAM CONTACT PERSONr\ Day Ph q (2=-.�j ;ght Ph IL' 4 1 PROGRAM ELErtENT U FEE I :a 11Surc7OF C3Other FEE INSPECTOR# (, _ Ptatntl I%/At.10 Z�ZO to _ 36 Z ❑ Food Handler ❑Che_•h x {,-)AAMOUNT PAID S�• Dato q _ INVOICE# 3__ 7DZ ❑ Cas1r f2rvff AT-n wv ACC(>jNTNG OFFK:F Dale �b — JLLu CQ4 (Anil 00 ILL RECORV INF01RIM f 10N PIMA