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S N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT R ;IyMF MASTERFILE RECORD INFORMATION FORM EcF/V�T ❑ New,EH Program at Existing Facility XNew EH Program and New Facili f ��N O Facili ID 001.7736, Pro ram Record ID 9a5 963 SANlO 2�2023 Facilit _Address_ qJ8 67ood Fgcr�RON�NC0 (Please check the appropriate description and specify s nu�er of unit�nd�plerti�information, y O�P�h'MENT Y Nr •FOOD PROGRAM 1600 �.Res urant: Seating Capacity Square Footage Food Handlers Course required: YES❑ No� gCom�issary ❑ Dry storage only ❑ with Food Preparation )Vending Machines Number of Units ❑ Reta�I 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: ❑ CalARP 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) CI PBR(2231) ❑ PBR HHW(2236) ❑ Aboyeground 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 El Jail or Exempt Institution----Number of Units Employer Housing(2700) Use Employee Housinq/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ EnviSonmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number f Pools/Spas at Facility El Pool El Spa ❑ Out of Service Pool/Spa El Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poul ry,Farm-----Maximum number of birds ElKennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Bod 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) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets---Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refu a Vehicles(#of units) ElDumpsters>20 cu yd(#of Units) ❑ Farm/Ranch Cleanup Site MEDICA WASTE PROGRAM(4500) ❑ Prim ry Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Tran tTER r Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 ❑ 11 -60 El >60 generators PUBLIC SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form ERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM � M COIVTA dT,PERSON Y :Day Ph —�J Night•Ph 7-700 O PROGRAm ELEMENT 1691 FEE 2 ❑ Surchargf FEE ❑ Other FEE INSPECTO # PERMIT VALID ,2 t0 (/30 2 ❑ Food Handler ❑ Check# a AMOUNT PAID •olip Date �2_ INVOICE# 3 TIT�3 ❑ Cash i REVIEWED BY ACCOUNTING OFFICE Date =2 48-02-034 MASTERFILE RECORD IN ORMATION PINK 1/23113 /— 742—