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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />"Facility <br />EH Program at Existing Facility <br />Facility ID Fico,7_7g,s-/ <br />(Please check the appropriate description and <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only 0 w <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make --Val-t <br />Registration # <br />Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />ONew EH Program and New Facility <br />Facility Address t -1 <br />Program Record ID Fikj()4g(X„q <br />lk_A_AiNnr\ <br />PAYMENT <br />RECEIVED <br />SEP 0 1 2023 <br />specify size, number of units and pertinent information.) SAN JOAQUIN COUNTY <br />HEALTrii DR:cytTMENT <br />ENVIRONMENTAL <br />quare Footage Food Handlers Course required: YES L-I <br />ith Food Preparation OVending Machines Number of Units <br />w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Vehicle Type Color 0-v-Qej--\ <br />License # Sticker # <br />Color <br />Sticker # q7CD7 <br />to 0 Ice Plant 0 Produce Stand <br />to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy <br />CUPA <br />0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />LI 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 />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 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 <br /> <br />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 # <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 yid units) 0 Dumpsters >20 Cu yd (tt of units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care LI 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 11 - 60 <br /> LI > 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 Day Ph Night Ph <br />Capacity Vehicle # <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />PROGRAM ELEMENT 1CW FEE <br />INSPECTOR # \ING1/4 0-e-E PERMIT VALID <br />El Check # AMOUNT PAID <br />El Cash REVIEWED BY <br />48-02-034 <br />1/23/13 <br />0 Surchar e F <br />to <br />Date <br />ACCOUNTING OFFICE <br />/6511131 <br />0 Other FEE <br />2_3 0 Food Handler <br />INvoicE# 3g <br />Date cr 1/23 <br />MASTERFILE R 0 INFORMATION PINK