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New EH Program at Existing Facility EIT\l'ew EH Program and New Facility Facility ID Facility Address t (7 Program Record ID SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM (Please check the appropriate description FOOD PROGRAM (1600) Restaurant: Seating Capacity Square Footage Commissary 0 Dry storage only 0 with Food Preparation 0 Retail Market----Square footage 0 w/Meat Market only Mobile Food Vehicle --Make Vehicle Type Registration # License # Mobile Food Prep Unit-- Make Vehicle Type Registration # License # Temporary Food Facility --Dates of operation from 40G 31 _ N 2023 N'/R8(-8NcouNT. R7-4,zNr Food Handlers Course required: YES 0 No 0 OVending Machines Number of Units 0 Multiple Departments 0 Prepackaged Goods Only Color Sticker # Color Sticker # to 0, I e Plant 0 Produce Stand CFO A 0 B and specify size, number of units and pertinent information.) Special Event---Dates of operation from to DAIRY PROGRAM (2000) CI Grade A Dairy CUPA 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit Hazardous Materials Business Plan (1900) Number of chemicals: CalARP Program CI Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility CI Hazardous Waste Generator (2200) >-Tons Generated Per Year Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) CI 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 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 0 Pool 0 Spa CI 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) CI 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) Pumper VehicleRegistration # License # Capacity Vehicle # CI Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) Landfill 0 Transfer Station El Ag/Cannery Waste Site O Sludge/Ash Site Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility O CIA Landfill Site CI Refuse Vehicles (# of Units) El Dumpsters > 20 cu yd (# of Units) O Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) El Primary Care 0 Acute Care 0 Skilled Nursing CI Large Generator CI Transfer Station 0 Veterinary Clinic 0 Common Storage Facility CI 2 - 10 31 48-02-034 1/23/13 Small Generator CI Limited Hauler CI 11 -60 0 > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form nAilf2..t EMERGENCY NOTIFICATION FOR THIS FA LIT AND/OR PROGRAM CONTACT PERSON 4"X‘t. ("I/0—r\ Day P "CS 72-7- (.,250 Night Ph PROGRAM E.L.FilENT1(0 O FEE 736 60 0 Surchar. FE 0 Other FEE INSPECTOR # 4,•LA I PERMIT VALID 4123 to 1. 0 Food Handler CI Check # AMOUNT PAID I. / %‘.Z.Z) Date 3,23 INVOICE# 3 Cash REVIEWEDTK , ci ' 27 I 2jSC ACCOUNTING OFFICE To Date ct / 2.3 aow 16.751(3,1 MASTERFILE RECORD NFORMATION PINK