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PAYMENT <br />RECEIVED RECEIVED <br />JUL 0 5 2023 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />Food Handlers Course required: YES 0 No 0 <br />[Wending Machines Number of Units <br />0 Multiple Departments0 Prepackaged Goods Only <br />Color <br />0 New EH Program at Existing Facility Iiew EH Program and New Facility <br />I Facility ID Program .7-77 6_5 Program Record ID 02097 LEZ2- <br />Facility Address S LSI Ntl , 9-0.-k / gi a <-14-4 0*1 I ( A 9 2-I S'' <br />(Please check the appropriate description and specify 2112, number of units and pertinent Information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant Seating Capacity ____ Square Footage <br />0 Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market—Square footage 0 with Meat Market only <br />Mobile Food Vehicle —Make Vehicle Type <br />Registration # License # Sticker # <br />Registration # License # Sticker # <br />Color 0 Mobile Food Prep Unit Make Vehicle Type <br />0 Temporary Food Facility —Dates of operation from to 0 ice Plant <br />0 Special Event Dates of operation from to 0 Produce Stand <br />DAIRY PROGRAM (2000) <br />0 Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />Mg 0 State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />Hazardous Waste Generator Tons Generated Per Year 0 Recycle/Exempt System (2299) <br />CRT Offsite Handlers (2218) 0 Silver Only (2222) 0 Appliance Recyclers (2217) <br />Tiered Permitting Facility 0 Conditionally Authorized (CA) 0 Conditionally Exempt (CE) <br />0 Permit-By-Rule Fixed Unit 0 Permit-By-Rule Household Hazardous Waste <br />ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <br />RUSiNG PROGRAM (2400) <br />Hotel/Motel —Number of Units 9 6 0 Jail or Exempt Institution —Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Came Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPLJSEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 2- XPool 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 />0 Tattooing (4121) 0 Body Piercing (4120) 0 Permanent Cosmetics (4122) <br />LiQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # Capacity Vehicle # <br />0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets —Number of Units <br />SOUD WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site <br />0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (5 of Units) 0 Dumpsters > 20 cu yd (s or units) 0 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 0 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 />EMERGENCY PIOT1FICAI1ON FOR THIS _FACILITY AND/OR PROGRAM <br />CONTACT PERSON illir4rww.a. "V- I PA S h L bet Day Ph 54 2- - ("1 (42- 41-C,ONight Ph <br /> 0 Other FEE <br />0 Food Handler <br />Iff2-3 INVOICE # 3g 3/ <br />.47 <br />j. Date 7/i3 j';-:5 <br />FEE 141.5 0 Surcharg <br />PERMIT VALID 71-5-/ 2-3 to P- / <br />it AMOUNT PAIe I 174 /- iD Date <br />BY ACCOUNTING OFFICE <br />PROGRAM ELEMENT 3611 <br />INSPECTOR g 9828 <br />El Check * (')ed <br />0 Cash REVIEWED z <br />MASTERFILE RECORD INFORMATION PINK <br />48-02-034 <br />11/15/07