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Date 4' 30 <br />MASTERFLE EGO INFORMATION PINK <br />EH Pro <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility ram and New Facility <br />ID i_)5-q--Ya3 <br />PA I, <br />iiiCrill47- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 JUN <br />84 N 9 2023 <br />A 11/IY Qb1A1 Facility ID F/ Z77 14T-- Program Record <br />Facility Address I I LI 0 5 , 0-r n-yu. tlitn 14-(14-4-e--/ <br />(Please check the appropriate description and specify size number of units and pertinent information ) <br />Food Handlers Course required: YES 0 No 0 <br />0Vending Machines Number of Units <br />El Multiple Departments 0 Prepackaged Goods Only <br />Color <br />El Special Event---Dates of operation from <br /> to 0 Ice Plant El Produce Stand <br />to 0 CFO 0 A 0 B <br />El Milk Dispenser-Number of Containers in Multi-Head Unit <br />Number of chemicals <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 12 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 />0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 Other CUPA Program <br />0 Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND <br />Environmental Assessment 0 UST-CAP Site 0 Local HW <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site El <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br />INJECTION CONTROL (3000) <br />Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />RWQCB Cleanup Site El Water Quality Remediation Site <br /> <br />0 Out of Service Pool/Spa 0 Natural Bathing Area <br />0 Kennel <br /> <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />0 Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicieRegistration # 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 <br />O Ag/Cannery Waste Site <br />O Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility <br />O Process/Recycle Facility <br /> <br />O CIA Landfill Site <br />Refuse Vehicles p of units) <br />O Dumpsters > 20 Cu yd (it of units) <br /> <br />O Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />0 Transfer Station El Veterinary Clinic 0 Common Storage Facility 0 2- 10 0 11 -60 0 >60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />A EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON 7 -capat.--7-7D-e _a_ Day Ph ci O —6 9c-93.24- Night Ph _51 o -69 g -V328:› <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />FOOD PROGRAM (1600) <br />0 Restaurant. Seating Capacity <br />Commissary El Dry storage only <br />Retail Market----Square footage <br />El Mobile Food Vehicle --Make <br /> Square Footage <br />1:1 with Food Preparation <br />w/Meat Market only <br />Vehicle Type <br />License # <br />Vehicle Type <br />License # <br />Sticker # <br />Color <br />Sticker # <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />0 Grade B Dairy <br />CUPA <br />Hazardous Materials Business Plan (1900) <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units <br />PROGRAM ELEMENT (C)2.5 FEE <br />INSPECTOR # \4 L PERMIT VALID <br />El Check # V / 3-- AMOUNT PAID <br />El Cash REVIEWED BY <br />0 Surch,r <br />to <br />Date 2? 2_3 INVOICE # <br />e F E 0 Other FEE <br />0 Food Handler <br />ACCOUNTING OFFICE <br />48-02-034 <br />1/23/13