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Square Footage <br />El with Food Preparation <br /> Li w/Meat Market only <br />Vehicle Type <br />License # <br />Vehicle Type <br />License # <br />New EH Program at Existing Facility <br />Facility ID <br />(Please check the appropriate description and specify size, <br />FOOD PROGRAM (1600) <br />CI Restaurant: Seating Capacity <br />CI Commissary CI Dry storage only <br />Retail Market—Square footage <br />Mobile Food Vehicle —Make <br /> <br />Registration # <br />0 Mobile Food Prep Unit-- Make <br /> <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />0 Special Event---Dates of operation from <br />PAYi <br />ECEiveo <br />'\i"V ° 7 2023 <br />SANJO <br />AQU iN Ack^ NTAL AR TmENT <br />Food Handlers Course required: YES El NO CI <br />OVending Machines Number of Units <br />CI Multiple Depytments CI Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />Sticker # <br />- 0 Ice Plant 0 Produce Stand <br />0 CFO 0 A 0 B <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />EINew EH Program and New Facility <br />Program Record ID • <br />Facility Address ) ri --)T: I'VAcci -51k c--4=t <br />number of units and pertinent information.) <br />DAIRY PROGRAM (2000) <br />CUPA <br />CI Hazardous Materials Business Plan (1900) Num <br />Li CalARP Program 0 Program 1 Facility <br />0 Hazardous Waste Generator (2200) >-Tons G <br />0 Tiered Permitting Facility > 0 CA (2232) Li <br />0 Aboveground Storage Tank Facility (AST) (2800) <br />0 Underground Storage Tank Program (UST) (2300) <br />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />0 Hotel/Motel -----Number of Units <br />Employee Housing (2700) Use Em io <br />SITE MITIGATION (2900) <br />Environmental Assessment 0 UST-CA <br />CI Abandoned HW Site Li non-NP <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum num <br />TATTOO BODY PIERCING PERMAN <br />Body Art Practitioner Reg (4 <br />CI Body Art Facility-Sterilizatio <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />ID Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (// or units) <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care 0 Acute Care 0 Skilled Nursing I=1 Small Generator <br />CI Transfer Station CI Veterinary Clinic CI Common Storage Facility 0 2 - 10 0 11 -60 <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 Tc: Day Ph0,--1, 2 (C-'1 2 Night Ph <br />0 Surcharge FEE 0 Other FEE <br />Li Cash <br />48-02-034 <br />1/2 3 /13 <br />0 Grade A Dairy 0 Mil 0 Grade B Dairy Dispenser-Number of Containers in Multi-Head Unit <br />ber of c micals: <br />rogram 2 Facility 0 Program 3 Facility <br />ene ted Per Year <br />E (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />Number of ASTs <br />se UST A and B forms <br />ee Housin <br />0 Jail or Exempt Institution ----Number of Units <br />Labor Cam • A • •lication Form <br />UNDERGROUND INJECTION CONTROL (3000) <br />Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />er of birds 0 Kennel <br />T COSMETIC PROGRAM (4100) <br /> License # <br />0 Package Treatment Plant <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />0 Large Generator 0 Limited Hauler <br />CI > 60 generators <br />PROGRAM ELEMENT icoog FEE <br />INSPECTOR # G-F PERMIT VALID to 0 Food Handler <br />0 Check # <br />_ <br />AMOUNT PAID Date INVOICE # <br />I Vo <br />REVIEWED BY ACCOUNTING OFFICE Date <br />L__047 i-. =41- 1716a7/- <br />MASTERFILE RECORD INFORMATION PINK <br />(..;) ft, I SS LA-e___ <br />0) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />(4121) CI Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event Mobile Facility (4131) <br />0 Ag/Cannery Waste Site 0 Sludge/Ash Site <br />0 Process/Recycle Facility 0 CIA Landfill Site <br />0 Dumpsters >20 cu yd (# of Units) 0 Farm/Ranch Cleanup Site