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�• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT FC �Nr MASTERFILE RECORD INFORMATION FORM �f F/V� ❑ New EH Program at Existing Facility _ New EH Program and New Facility "l��j' O 0 Facilit ID OD�779 Program Record ID /L4Sy�(PU� SqN JpgQU ,2023 Facility Address 4 oo -u yo Y C C� -�1-� rhoF FNOONTy (Please check the appropriate description and specify size, number of units and pertinent information.) �RTMFNT FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ,1�Retail Market---Square footage 3 o C ❑ w/Meat Market only ❑ Multiple Departments K 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: ❑ CaIARP 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) ❑ PBR (2231) ❑ 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) ❑ Hotel/Motel----Number of Units ❑ Jail or Exempt Institution --Number of Units Employee Housing (2700) Use Employee Housinq/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental 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 of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm----Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Body 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 (440C) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#or Units) ❑ Dumpsters>20 cu yd t#of Units; ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENC NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM p CONTACT PERSON Day Ph o —� Night Ph '2 6-7 / PROGRAM ELEMENT �T,, FEE JO 1 ' El Surcharge FEE v El Other FEE INSPECTOR# �� 1, `Ol(' PERMIT VALcI� Z -I'2) 2 to ,1,2^ Food Handier ❑ Check# I/1 SGe_ AMOUNT PAId" 30�•�� Date .0 INVOICE -Z� ❑ Cash REVIEWED BY ACCOUNTING OFFICE 6y& Date 48-02-034 �� MASTERFILE REC RD INFORMATION PINK 1/23/13