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Apr 05 22 02:43p Century 21 M&M & Assoc. 209-334-2550 p.3 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFiLE RECORD INFORMATION FORM (P!ease check the appropriate description a.nd specify size, number of units and gertiient information.) FOOD PROGRAM (1600) PAYMENT RECEIVED AUG 15 2022 SAN JOAQUIN COUNTY ENVIRONMENTAL NEgLTH DEPARTMENT ❑ Restaurant: SeatiFood Handlers Course re ufred:ng Capacity Square Footage YEs ❑ No O El Commissary 11 Dry storage oily El with Food Preparation ElVending Machines Numbcr of Units El Retail Market ---Square footage ClwlMeat Market only ❑ A9ultiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle --Make- _ Vehicle Type Color _ Rec,stration # License 4 Sticker # ❑ Mobile Food Prep Unit-- Make Venide Type ! Color Reclstration # License It _ Slicker # 11 Temporary Food Facility --Dates of operation from :o _ El Ice Plant El Produce Stand ElSpocial Event ---Dates of operation from to ❑ CFO CIAO B DAIRY PROGRAM {2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Contamers in t11a Head Unit CUPA ❑ Hazardous Materials Business Plan (10.00) Number of chemicals. ❑ CaIARP Program El Program 1 Facility 11 Program 2 Facility El Program 3 Facility ❑ Hazardous Waste Generator (2200) -------->-Tons Generated Per Year ❑ Tiered Permitting Facility -------> ❑ CA (2232; ❑ CE (22330 2234, 2235, 2237) ❑ PBR (2231) ❑ PBR HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2.800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Uso UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ HotellMotel ------Number of Units ❑ Jail or Exempt Institution----Numbe" of Units Employee Housing (2700) Use Employee HousinalLabor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) El Environmental Assessment ❑ UST -CAP Site El Local HW Cleanup Site ElNPLISEP Cleanup Site [3 UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCS Cleanup Site ❑ Water Quality Remediatlon Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑Pool D Spa El Out of Service PooliSpa ❑Natural Bathing Area VECTOR CONTROL PROGRAM (40001 D Poultry Farm---•---fvlaxilnurr number of birds ❑ Kennel TATTOO BODY PIERCING* ,PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110] ❑Mechanical OSPS Notification (4115) Body Art Facility -Single Use (4170) ❑ Body Art Facility-Sterilizatlon (4121) ❑ Body Art Temp Event Co-ord (4130) 11 Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper VelticleRegistration # License # _ El Purn per Yard ❑ Package Treatment Plant SOLID WASTE PROGRAM (4400) El Landfill ❑Transfer Station ❑ Waste Tire Facility ❑ Compost Facility El Refuse Vehicles (s of Units) MEDICAL WASTE PROGRAM (4500) Primary Care ❑Acute Care El Sk111ed ❑ Transfer Station L3 Veterinary Capacity Vehicle # ❑ Chemical Toilets---Nur7ber of Units _____ ❑ AglCaltnery Waste Site ❑ Sludge/Ash Site ❑ ProcesslRecycle Facility ❑ Dumpsters > 20 cu yd ;k of Units) ❑ CIA Landfill Site ❑ Farm/Ranch Cloanup Site ❑ Nursing [2 Large Generator ❑Small Generator ❑Limited Hauler ❑Common Storage Facility ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46.02.003 Slue Application Form Clinic CONTACT PERS Jay Pi - PROGRAM ELEMENT, +•� I a0 _ FEE _,Z 3 / ❑ Surclia INSPECTOR # '7O � �+ _ PLItt.4i'r VP\LIIZ 8 (S ZrZ t0 ❑ Check 0 �— AMOUNT PAID 2D - 0U D91e ❑ Cash R: VI YfGO OY AGGOUK TIYG OFFIG'_ 48.02-054 rn�rs Z43 fJignl Fr 1�1' FE ❑Other FEE ❑ Food Handler ZZ INVOICE 9 jeo�S —^ Date 8 Z2— MASTERFILE RECOFfDO INFORMA11014 PINE: