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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br /> <br />New EH Program at Existing Facility <br /> <br />New EH Program and New Facility <br />Facility ID F A Pliz::O277 4-15- Program Record ID aD:543-53"7 <br /> <br />Facility Address I 1 <br />and specify size, number of units and pertinent information.) <br />Square Footage <br />E' with Food Preparation <br />w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />License # <br />Food Handlers Course required: <br />CIVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br /> Color <br />Sticker # <br />Vehicle Type Color <br />License # Sticker # <br /> <br />Registration # <br />Mobile Food Prep Unit-- Make <br /> <br />Registration # <br />PAYNIENT <br />RECeivED <br />JON 2 9 2023 <br />SAN JOAQUI <br />N HEALTH NMENTC°UNTYAL <br />'EPARNENT <br />YES No 0 <br />(Please check the appropriate description <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />12v6ommissary 0 Dry storage only <br />Retail Market----Square footage <br />PROGRAM ELEMENT 6g ( FEE <br />INSPECTOR # 8 2 PERMIT VALID <br />Check # AMOUNT PAID <br />Cash REVIEWED BY <br />to <br />Date <br />ACCOUNTING OFFICE <br />0 Surchar e FE <br />6 30 <br />610 <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />El Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) ›-Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units 0 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 />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation 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 />Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />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 />Pumper VehicleRegistration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (tt or Units) 0 Dumpsters > 20 Cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 ii - 60 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />— <br /> I , <br />E E <br />Day Ph <br />GENCY NOTIFICATION FOR THIS FACILITY 0/OR PROGRAM <br />CONTACT PERSON 153t C alight Ph <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />0 > 60 generators <br /> 0 Other FEE <br />El Food Handler <br />INVOICE # 3 E <br />Date e/3723 <br />MASTERFILE R CORD INFORMATION PINK 48-02-034 <br />1/23/13 cot 16+434-SOS-