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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility tpNewEH ❑ Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) '� Program and New Facility Facility ID r Od 2� % 1. , Program Record ID n54 17? PAYMENT RECEIVED JUN 0 6 2022 SA ENVIRONMENT LTY HEALTH DEPARTMENT Facility Address 3031 w. air Ch 1_n . tSU i -1e 104 S Stn6kton, UA LM219 (Please check 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 ❑ Retail Market• ---Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle --Make Vehicle Type Color Registration # License # Sticker # ❑ Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # ❑ Temporary Food Facility •-Dates of operation from to ❑ Ice Plant ❑ Produce Stand ❑ Special Event ---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser -Number of Containers in Multi -Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator (2200) ---------- >-Tons Generated Per Year ❑ Tiered Permitting Facility ---•---> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑PBR (2231) ❑ PBR HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm• --•••-Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) LIQUID Ag/Cannery Waste Site ❑Sludge/Ash ❑ Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) '� Body Art Facility -Single Use (4120) ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration # License # ❑ Package Treatment Plant SOLID WASTE PROGRAM (4400) ❑ Landfill 1:1 Trans Station Capacity Vehicle # 11 Pumper Yard ❑ Chemical Toilets --•-Number of Units 11 El Waste Tire Facility 1:1 Compost Facility El Refuse Vehicles (# of units) Ag/Cannery Waste Site ❑Sludge/Ash Site ❑ ProcesslRecycle Facility ❑CIA Landfill Site ❑ Dumpsters > 20 cu yd (# or unite) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application ❑ Primary Care 11 Acute Care 11 Skill Nursing 11 Large Generator El Small Generator ❑Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 -60 ❑ > 60 generators Font -?pq _qIS' - 3 141 CONTACT PERSON Day Ph � e ��. Night Ph PROGRAM ELEMENT � I.1 � FEE �% ❑ Surcharg FE ❑Other FEE INSPECTOR# PERMITVALID 0 to13 20, ❑ Food Handier ❑ Check# AMOUNT PAID 5& nn Date (0 INVOICE# 11Cash REVIEWED BY ACCOUNTING OFFICE / Date QvZ1, 4&02-034 J // 4 /�7S/��7 7123/13 /`'-v,(��,�Cly