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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />CI New EH Program at Existing Facility ew EH Program and New Facility <br />Facility ID F4a92:772_61 Program Record ID FRAs-q-gs-)o <br />Facility Address 1865 W 11th St., Tracy, CA 95376 <br />PAYMENT RECEIVED <br />JUN 2 1 2023 <br />SAN JOAQUIN <br />CUNTY ENV/ONMENOTAL HEALTHR <br />DEPARTMENT <br />(Please check the appropriate description <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity 12 Square Footage 960 <br />Commissary CI Dry storage only CI with Food Preparation <br />CI Retail Market----Square footage El w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # <br />and specify size, number of units and pertinent information.) <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br /> Color <br />Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant CI Produce Stand <br />Special Event---Dates of operation from to 0 CFO 0 A CI B <br />DAIRY PROGRAM (2000) <br />CI Grade A Dairy 0 Grade B Dairy CI Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program CI Program 1 Facility CI Program 2 Facility 0 Program 3 Facility <br />CI Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />CI Tiered Permitting Facility > 0 CA (2232) CI CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units CI 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 />CI Environmental Assessment CI UST-CAP Site 0 Local HW Cleanup Site CI NPL/SEP Cleanup Site 0 UIC Site <br />Cl Abandoned HW Site 0 non-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site CI Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool CI Spa CI Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br /> CI Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) <br />CI 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 />CI Pumper Vehicle Registration # License # Capacity Vehicle # <br />CI Pumper Yard CI Package Treatment Plant CI Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM <br />CI Landfill <br />CI Waste Tire Facility <br />CI Refuse Vehicles (# of <br />(4400) <br />Transfer Station <br />Compost Facility <br />Units) <br />El Ag/Cannery Waste Site <br />CI Process/Recycle Facility <br />0 Dumpsters > 20 cu yd (# of Units) <br /> <br />CI Sludge/Ash Site <br />CI CIA Landfill Site <br />CI Farm/Ranch Cleanup Site <br /> <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care CI Acute Care CI Skilled Nursing 0 Large Generator <br /> 0 Small Generator 0 Limited Hauler <br />CI Transfer Station CI Veterinary Clinic CI Common Storage Facility CI 2 - 10 CI 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 />CONTACT PERSON Michael Cuison Day Ph 925.428.7008 Night Ph 925.428.7008 <br />PROGRAM ELEMENT k ko'n FEE 35 CI Surcharge FEE 0 Other FEE <br />INSPECTOR #\4-1 t-- PERMIT VALID kc-1 ' 2! - to (0 2_ CI Food Handler <br />1:1 Check # _V 14-5%t— AMOUNT PAID #35-6.0r) Date 6 2-3 INVOICE # ; <br />Cash REVIEWED BY ACCOUNTING OFFICE Date 6 <br />48-02-034 MASTERFILE RECORD INF RMATION PINK <br />5 QQ ck-k-VoN. ezixt? &.L1L- 1/23/13