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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility <br />ONew EH Program and New Facilit <br />Facility ID rA <br /> <br />Program Record ID P21:5'1-877 .'7 <br />3S-- FEE <br />PERMIT VALID <br />AMOUNT PAID <br />c 0-vr) , c ci E 10 t) <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />PAYMENT <br />RECEIVED <br />NOV 0 6 2023 <br />Facility Address 7-1-MO 5, f-31-900- <br />(Please check the appropriate description and specify size, <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />Commissary 0 Dry storage only CI with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />.,.?Mobile Food Vehicle --Make <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br /> Color <br />Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />number of units and pertinent information.) <br />Vehicle Type <br />License # <br />Vehicle Type Color <br />License # Sticker # <br />to 0 CFO CIA013 <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />CI Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units 0 Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />0 Pumper Vehicle Registration # License # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station El Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility CI Process/Recycle Facility <br />Refuse Vehicles (# of units) El Dumpsters > 20 cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care CI Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 CI 11 - 60 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />1 <br /> <br />'1CtV YloOlc {)(; <br /> <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> <br />Day Ph 5)0 517 L17 Night Ph 5 1 0 61 7 3 <br />0 Kennel <br />Capacity Vehicle # <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />0 > 60 generators <br />CONTACT PERSON <br />REVIEWED BY <br />PROGRAM ELEMENT <br />INSPECTOR # <br />Check # <br />Cash <br />48-02-034 <br />1/23/13 fqF <br />/7/57 7-7/ <br />0 Surchargq F <br /> <br />to J2I3f 2- <br /> <br />Date it <br />Other FEE <br />Food Handler <br />INVOICE # 3 <br />Date <br />MASTERFILE RECORD I FORMATION PINK <br />ACCOUNTING OFFICE