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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />C] New EH Pro_grarn at Existing Ficilily <br />Facility ID F-A,,,a_7 <br />Facility Address -? C 1A1A1 Not),--'7 AINOAtAISC,0161;11 <br />died, Vie aKrocioale description andsee-",:itY We, number of units and petelnent InforMatlen-1 <br />FOOD PROGRAM (1600) <br />0 Restaurant Se Capacity Square Footage <br />o Oviiiiiiiaaary 0 Pry ;•IVIOVC U'lly <br />0 Retail Market --Square footage 0 wAteat Market onty <br />Li Mobile Food Vehicle —Make Vehicle Type <br />Registral.tin A License, a <br />O Mobile Food Prep Unit— Make Vern cle Type <br />ReQistrlor# LC:wise <br />O Temporary Food Facility --Dales of operation from <br />17I 5 peciai evern—rmres of uperiatiun hum iv <br />Program Record ID Pe,05-4)-g--/ <br />SZ:Nlew EH Program and New Facility <br />SEP 15 2023 <br />SAN JOAQUIN COUNTY ENVIR ONMENTAL <br />HEALTH DEPARTMENT <br />Food Handlers Course required: Yes 0 Ne 0 <br />OVondin9 Maoh4rko•Nurr.bor cp( Urnts _- <br />0 Multiple Oepartments 0 Prepaditaged Goods Only <br />Golor <br />Slicker* <br />Color <br /> Slicker* <br /> 0 Ice Plant 0 Produce Stand <br />iCro NIA n <br />PAYME NT <br />RECEIVED <br />18-02-05-s <br />'-Pkecr-zsz_ <br />MASTERFUE RECORD INF R MAT IC 14 DIN <br />9(r42%;‘1. <br />DAIRY PROGRAm (2000) <br />0 Grade A Dairy <br /> 0 Grade B Miro 0 Milk Dispenser •ra_rriter Conners in Multi-Head int _ _ <br />EULA„ <br />11:Undergrou ndna Adl RrdP6u <br />Program <br /> m I ut I 1 I 96 el 3TuiriiriPuroP%lairignft (I lICS1)1 i220Cijiiubc yr c53frchAigmiVicalSivirrna <br />Prugrarn 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />U Hazardous Waste Generator ("2:`0,1 Cneralerl Per Year <br />0 Tiered Permitting raniidy CA CE (2233. 2234, 2235, 2237) 0 PBR (2231) 0 PBR NNW (22381 <br />0 Aboveground Storage Tank Facility (AST) (2600) 1/4ionrhlaer of ASTs <br />0 Other CU PA Pregrarn <br />NUSING PROgKA.M12400) <br />0 liotalfMota I If-arbor Unit 0 Jail or Exempt institution th,Jmb or of Unita <br />Eniployee Housing (27:10) tire Employee Heualnoitabor Camp Application Form <br />aujiThca_r_2N12soci-, LysIDE9GriCit.iNcii NECTIQN cQNTRO I. y30001 <br />0 Environmental Assessment 0 UST-CAP Site 0 Local H1N Cleanup Site 0 NPUSEP Cleanup Site 0 tJIC Site <br />0 Abanooneo MN Site 0 non-NP LJSEP Cleanup Site 0 RYVQCI3 Cleanup Site 0 Water Quality Remeciation Site <br />RECREATIONAL HEAL.T1t PROGRAM k:M:•00'.1 <br />n' PecIsirSiras at Facility El Pool 0 Spa 0 Out of Service PooVSpa 0 Natural Bathing Area <br />VECTOR CONTROL PROORAM i 4003, <br />0 Poultry Farm chzeitict ol b ids <br />TATTOO, BODY PIERCING. PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (411C; 0 Mechanical DBPS Notification (4115) 0 Body Art Facility-Sins& Use 11120) <br />Cl MALI y A.1-T.,vg) c. mows/ roomy (4101) <br />LIQUID WASTE PROGRAN ;42C0) <br />0 Pumper VehiclePegisinicion License * <br /> <br />C:74r.a,7.1).? 'WehRde * <br />0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets lq.imber of Units _ <br />SOLID WASTE PROORAM (44301 <br />U Laudriii <br /> <br />L7 Transfer SLetiuui 13 AgrCannery Waste Site 0 SlutigeitAsh She <br />El Waste Tire Facility <br /> <br />0 Compost Facility 0 ProCessrRe cycle Facility 0 CIA Landfill Site <br />Li Peruse VohicleS a(1 , Jr lt,1 Dun r psters 20 cu yd a i/ FarmfRanch Cleanup Site <br />MEDICAL INA.CTS przocnAm <br />0 Primary Care 0 Acute Care Skilled Nursing 0 Large Generator 0 Small Generator Li Limited Hauler <br />0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 - 10 0 i - 60 080 Renerwtors <br />PUBLIC WATER SYSTEM PROGRAM (461001 JS /VS MD 4it02,42Q3 Blue Application "-arm' <br />EMERGENCy NOTIMACTION toR rmis FACILITY ANIYOR PROGRAM <br />CONTACT PERSON NEttiPi RIKANANDANI Nay 5^ CU 1, 6 1- I 111 ) Nght Ph _cQkj67,11-110 <br />0 Kennel <br />Ocatly Act roc-clay-nig:I ciccoltoorc 01:71) 0 13accly Art Temp cv.rd. (413e) <br />PROQRAM ELEMENT \‘00(i..,„ FLE 1C:::1 0 Surcharge FEE <br />IP,6PECTOR di kiSal9 PERMIT VALID lel ' i 0. 3 to 1 • %- <br />ttche..i.. S ic., MOUNT PAID l 43 b ---- Dale I D 2.3 <br />0 tasn IStkvklowl) BY RCUOIJN IING OFFICE <br />0 Other FEE <br />0 Food Handler <br />INVOICE <br />Uate <br /> 23