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El Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 Cu yd 14 ,'iis <br />0 Sludge/Ash Site <br />CI CIA Landfill Site <br />CI Farm/Ranch Cleanup Site <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />rANew EH Program and New Facility <br />PAYMENT <br />RECEIVED <br />MAY 0 9 2023 <br />SAN JOAQUIN COUNTY <br />Facility ID FA 6027 &,.3 Program Record ID TROS14-S'I-131 <br />ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />Facility Address kotb$6- S • is...loyal-MN K ID-U -5 P v\NA/./ 4 (S0, \\./N ou i4rU1/4 ‘ NI 1-10LS <br />CP% otS3q1 <br />Square Footage aot SC <br />0 with Food Preparation <br />w Meal Market only <br />Vehicle Type <br />License # <br />to <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 />CI 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 > CI CA (2232) CI CE 12233. 2234, 2235 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />ID Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units I=1 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-NPL/SEP Cleanup Site CI RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool CI Spa CI Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM 4 <br />El Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification !411", 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord i4130 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration #License tt Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant El Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility CI Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing El Large Generator CI Small Generator CI Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility CI 2 - 10 0 11 - 60 Cl > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Y., Po- \ Ti 0 ss RA),:.; ti Day Ph ACQ-6201-2.0 0 2Jight Ph A-Oik. 6,07- X642 <br />PROGRAM ELEMENT \ ki12- FEE -R. 0 Surcharge FEE 0 Other FEE <br />INSPECTOR # (..:\14\0•4 PS PERMIT VALID 2- • 23 to -/3q2 0 Food Handler <br />Check # VI ..A_...- AMOUNT PAID 37C, ,OO Date INvoicE# g Oq-3 <br />Cash REVIEWED BY AO ACINo OFFR E Date 5 <br />New EH Program at Existing Facility <br />(Please check the appropriate description and specify size, number of units a ml pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity 91. <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />Vehicle Type <br />License # <br />to <br />Food Handlers Course required: YES DR No 0 <br />OVending Machines Number of Units <br />0 Departments 0 Prepackaged Goods Only <br /> Color <br />Sticker # <br /> Color <br />Sticker # <br /> El Ice Plant 0 Produce Stand <br />0 CFO 0 A 0 B <br />1/23/13 d-61/( rcre, S-76 6, <br />48-02-034 MASTERFILE RECORI INFORMATION PINK