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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM kir New EH Program and New Facility Facility ID rAcO.2.7 711 Facility Address IC: (.1.f-V /"Zet_J-7i2 c-i New EH Program at Existing Facility Program Record ID -pip s4s5-1-3 qc3 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) Restaurant: Seating Capacity Square Footage Commissary 0 Dry storage only 0 with Food Preparation Retail Market----Square footage VZMobile Food Vehicle --Make License # w a Lit) 4. / Registration # Mobile Food Prep Unit-- Make Vehicle Type Registration # License # Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand Special Event---Dates of operation from to 0 CFO 0 A 0 B Food Handlers Course required: YES 0 No 0 OVending Machines Number of Units 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only Vehicle Type Color Sticker # Color Sticker # PAYAgENT ReCeiveo JUN 3 2023 stJ0AQuiN 0 ffe;117.Rolvmec49Nry I"DEPARTAZNT PROGRAM ELEMENT 0 33 FEE 171 doe INSPECTOR # 11- )a-nnarcakIIT VALID 3A 23 Check # AMOUNT PAID 4/1. al Oil Cash REVIEWED BY ACCOUNTING OFFICE INVOICE # 3F,22L,s— o Surchar e F E 0 Other FEE to / 23 0 Food Handler Date Date 2.3 DAIRY PROGRAM (2000) Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit CUPA Hazardous Materials Business Plan (1900) Number of chemicals: El CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility Hazardous Waste Generator (2200) >-Tons Generated Per Year Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 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) CI Hotel/Motel Number of Units 0 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 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility Cl Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) Poultry Farm Maximum number of birds 0 Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) 0 Pumper VehicleRegistration # License # Capacity Vehicle # Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) 1:1 Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site Waste Tire Facility 0 Compost Facility El Process/Recycle Facility 0 CIA Landfill Site Refuse Vehicles or of Units) El Dumpsters > 20 cu yd (5 of units) CI Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2- 10 0 11 -60 0 >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM , Day Ph .(_'`• •1 (,) r2 Night Ph _ , 48-02-034 1/23/13 ca )0 e,e,-73? MASTERFILE RECORb INFORMATION PINK CONTACT PERSON