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RNA Oil PIN <br />X 20230530144853874.pdf <br />PDF - 2 MB <br />• • <br /> <br />1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERF1LE RECORD INFORMATION FORM <br />New EH Program I Existing Facility ONew EH Program and Nekv‘iii.15 <br />ft Feat ID tea, Program Record IOW . <br />Facility Address 41_13_ efiyilicAlze,s ZA) 47.5;9-0 V <br />(Please check Me appropriate description and spedfy gin, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />arRestaurant Seating Capacity Square Footage Food Handlers Course reauired: reek No 0 <br />0 Commissary 0 Dry storage only 0 with Food Preparation °Vending Machines Number of Units <br />0 Retail Market---Square footage 0 w/Meat Markel only 0 Multiple Departments 0 Prepackaged Goods Only <br />0 Mobile Food Vehicle —Make Vehicle Type Color <br />Registration d Licensee Sucker a <br />0 Mobile Food Prep Unit.- Make Vehicle Type _ Color <br />Registration X License e Sticker It <br />0 Temporary Food Facility —Dates of operation from to 0 Ice Plant 0 Produce Stand <br />0 Special Event--Dates of operation horn_ to _ 0 CFO 0A0B <br />DAIRY PROGRAM 120001 <br />0 Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser -Number &Containers in Muth-Head Unit <br />CUPA <br />0 Hazardous Materials Business Plan 11900) Number of chemicals: <br />0 CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />0 Hazardous Waste Generator (2200)----> -Tons Generated Per Year <br />0 Tiered Permitting Facility 0 CA (2232) 0 CE (2233, 2234, 2235, 22371 0 PBR 12231) LI PBR HHW (2236) <br /> <br />Aboveground Storage Tank Facility (AST) (2600) Number of ASTs _ <br />Underground Storage Tank Program (UST) (2300) LI. UST A arid B forms <br />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />0 Hotel/Motel ----Number of Units 0 Jail or Exempt Institution --Number ol Units -- <br />Employee Housing 127001 Use Employee HouslnalLabor Camp Application Form <br />SITE MITIGATION (2900) UNOERGED INJECTION CiNTR.Q.L. (3000) <br />0 Environmental Assessment O UST-CAP Site 0 Local NW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />0 Abandoned NW Site 0 non-NPLISEP Cleanup Site 0 RWC1CB Cleanup Site 0 Water Quality Remediallon Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _ 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />0 Poultry Farm---Maximum number of birds 0 Kennel <br />TATTOO. BODY PIERCING, PEFtMANENT COSMETIC PROGRAM (4100) <br />0 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 (41301 0 Body Art-Temp Event Mobile Facility /4131 ) <br />LIQUID WASTE PROGRAM (4200) <br />Lirense Vehicle IS 0 Pumper VehicleRegistration Capamly <br />0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) <br />o Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site <br />0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />0 Refuse Vehicles pi 0 Do/Tipsters n 20 Cu yd rul ;His) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (45001 <br />0 Printery Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2- 10 0 11 -60 0 60 generators <br />PUBLIC WATER SYSTEM PROGRAM /46001 Use PWS END -02-003 Blue Application Form <br />I _ <br /> <br />EMERGENCY NOT 10 FOR TV AND/OR PROGRAM <br />CONTACT PERSON I MIMI Ph <br />PERMIT V. 0 Food Hand at <br />AMOUNT P• V_Co Date (SPOILT # a <br />REVIEWED Co ACDOLINTING OPPICE Dale <br />MA/THEM RE <br />PROGRAM ELE <br />IECTOR <br />Check C <br />Cash <br />48 02-034 <br />103,4 <br />FE r cc 0 Other FEE 0 Surch&r,