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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility New EH Pro ram and New Facility Facilit jD G?j Program Record ID z Facility Address I I50 LU, ?k1pjoir)h00& PY. (Please deck the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity. Square Footage Food Handlers Course required: YEs ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ RetailMarket---Square footage ❑ w/Meat Market only ElMultiple Departments ElPrepackaged Goods Only 11 Mobil Food Vehicle—Make 0 0 Registration # Food Prep Unit— Make Registration # ary Food Facility —Dates of operation Event—•Dates of operation from. Vehicle Type Color License # Sticker # Vehicle Type Color License # Sticker # to ❑ Ice Plant ❑ Produce Stand to El CFO ❑A❑B AI ❑ Grad A Dalry 11YA ❑ Grade D Dairy Milk Dispenser-Numbor of Containers in Mulg4lead Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIAFlops Waste Generator (2200)----> -Tons Generated Per Year El Tiered P2;T,Ilttiny o�•ai:iFiy------> ❑ CA (2232) ❑ CE {2233, 2234, 2235, 2237) ❑PBR (2231) ❑ PBR FitiW (2236) P Program 11 Program 9 Facility 111 Program 2 Facility El Program 3 Facility 11 Hazar 11 Abor I ground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use USTA and B forms ❑ Other CUPA Program HO USINGPROGRAM (2400) 11Hoteiilhotol---Number of Units ElJail or Exanipt ktstitVilon =--•Nurnborof Units Employee Housing (2700) Use Employee Houslna/Labor Camp Applicados Fom, if SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑UST -CAP Site ❑Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Slte ❑ Aban oned HW Site ❑non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site E3 Water Quality Remediation Site RECREAT ONAL f13A1.'17N PROGRAPA (3600) Number o Pools/Spas at Facility. ❑Pool 11 spa 11 Out of Service Pool/Spa 13 Natural Bathing Area VECTOR QONTROL PROGRAM (4000) ❑ PoultrFarm--Maximum number of birds 13 Kennel TATTOO, ODY PIERCING PERMANENT COSMETIC PROGRAM (4100) Body It Prac[fiiunar Rcg (4110) ❑ [i:::oha:xiva: DS" K a;icz[iatt (4if.,) ❑ Ltury N.. Use (1120) ❑ Body rt Facility -Sterilization (4121) 13 Body Art Temp Event Ce-ord (4130) ❑Body Art -Temp Event Mobile Facfisfy (4131) ❑ Pump r Vehicle Registration # License # Capacity Vehicle # ❑ Pump r Yard ❑Package Treatment Plant ❑Chemical Toilets --Number of Units Sx"i1.JDb"Y TE ?IIL'CsRA3d (4400) ❑ Landf I 11 Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility El Compost Facility ❑Process/Recycle Facility El CIA Landfill Site ❑ Rufus Vehicles (n or units) ❑ Dumpsters > 20 cu yd (nor units) ❑ Farm/ Ra�gh Cleanup Site MEDICAL ASTE PROGRAM (4500) I" YMr.A'7� ❑ Primp Care ❑ Acrtf_ Curd ❑ SF:}nett N:=.rsjci() ❑ La_g_: Dcrrss=__.; Carr•lm£ar"p��F�� 11 Trans er Station ❑Veterinary Clinic 13 13 Storage Facility 132 -10 E311 - 60 ❑ > 66gDrs PUBLIC ATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form SEP 17 2021 I EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM Re•, ._ ❑ Check ❑ Cash 4e-02-034 1/23!13 PERSON UIM(U 1 1/ L W i l LLfAy}l� Day Ph Night ELEA1gNT f.' 11 �_ SEE li ✓! ❑ Su'. � PERMIT VALID— t0 illII�b_ - , AMOUNTPAID Date REVIEWED BY ACCOUNTING OFFICE ❑ Othar FEE • mac/ _ ❑Food Handler _ INVOICE# <7 Date 1/0q/0 MASTERFILE REC RD NF Facfisfy (4131) ❑ Pump r Vehicle Registration # License # Capacity Vehicle # ❑ Pump r Yard ❑Package Treatment Plant ❑Chemical Toilets --Number of Units Sx"i1.JDb"Y TE ?IIL'CsRA3d (4400) ❑ Landf I 11 Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility El Compost Facility ❑Process/Recycle Facility El CIA Landfill Site ❑ Rufus Vehicles (n or units) ❑ Dumpsters > 20 cu yd (nor units) ❑ Farm/ Ra�gh Cleanup Site MEDICAL ASTE PROGRAM (4500) I" YMr.A'7� ❑ Primp Care ❑ Acrtf_ Curd ❑ SF:}nett N:=.rsjci() ❑ La_g_: Dcrrss=__.; Carr•lm£ar"p��F�� 11 Trans er Station ❑Veterinary Clinic 13 13 Storage Facility 132 -10 E311 - 60 ❑ > 66gDrs PUBLIC ATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form SEP 17 2021 I EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM Re•, ._ ❑ Check ❑ Cash 4e-02-034 1/23!13 PERSON UIM(U 1 1/ L W i l LLfAy}l� Day Ph Night ELEA1gNT f.' 11 �_ SEE li ✓! ❑ Su'. � PERMIT VALID— t0 illII�b_ - , AMOUNTPAID Date REVIEWED BY ACCOUNTING OFFICE ❑ Othar FEE • mac/ _ ❑Food Handler _ INVOICE# <7 Date 1/0q/0 MASTERFILE REC RD NF