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SAN JOAQUiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br /> <br />0 New EH Program at ExIstin • Facili <br />Facilit ID <br />w EH Pro ram and New Facilit <br />4i3 ram Record ID 00;76 <br />Facility Address 0<- <br />Day Ph Night Ph <br />GE 0 Other FEE <br />0 Food Handler <br />INVOICE #/ <br />Date fc, <br />MASTERFILE et-E. R iNFoRmATtON PINK <br />PROGRAM ELEMENT —3 6 I I FEE <br />>11 <br />O Surcharge <br />to <br />06 Date <br />INSPECTOR # <br />0 Check # <br />Oath <br />48-02-034 <br />1,231:1 <br />PERMIT VALID <br />AMOUNT PAID <br />2, <br />CONTACT PERSON <br />REVIEWED BY <br />e_zx <br />ACCC.:•.ATiiitO OFFICE <br />PAYMENT <br />RECEIVED <br />MAY 0 3 2023 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT (Please check the appropriate description and spea <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />O Rota Market--Square footage <br />0 Mobile Food Vehicle --Make <br />Registration # <br />0 Mobile Food Prep Unit- Make <br />Registration # <br />size number of units and pertinent info ation.) <br />License # <br />Vehicle Type <br />License # <br /> <br />Sticker # <br /> Color <br />Sticker # <br /> <br />Square Footage Food Handlers Course required: YES 0 No <br />0 with Food Preparation OVending Machines Number of Units <br />0 wiMeat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br /> Vehicle Type Color <br />0 Temporary Food Faculty -Dates of operation from to 0 Ice Plant 0 Produce Stand <br />0 Special Event—Dates of operat:on 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 Un t <br />CUPA <br />0 Hazardous Materials Business Plan (1900) Number of chemicals. <br />CalARF 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 RBR (2231) 0 PBR HHW (2236) <br />0 Aboveground Storage Tank Facility (AST) (2900) 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 />0 Hotel/Motet --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 MW Cleanup Site 0 NPL/SEP Cleanup Site 0 in Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3§c0) <br />Number of Pools/Spas at Facility L-t' M'Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <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 />0 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 VehicieRegistration # License # <br />Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles W. of Uruis) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />O Transfer Station 0 Veterinary Clinic 0 COIMTIOR Storage Facility 0 2 - 10 0 11 -60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />Capacity Vehicle # <br />0 Chemical Toilets —Number of Units <br />Ag/Carinery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd te of Untis) <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site