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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ~- MASTERFILE RECORD INFORMATION FORM RECEIVED PAYMENT AYIWENT ❑ New EI l Pro ram at Existing Facilit ❑New EH Program and New Facilit Facility ID 2S Program Record ID 5 _ IAN 31 2024 Facility Address ` c` �,`,,� `,-}. �l ,�r ,I l {;i SAN JOAQUIN COUNTY ENVIRONMENTAL (Please check the appropriate description and speedm y sire,nuber of units and pertinprit Informa tonHEALTH H DEPARTNT FOOD PROGRAM(1600) ❑Restaurant Seating Capacity _ 5yuare Footage i Ci Food Handlers Course required Ylsax No ❑ ❑ Commissary 11DIy storage only ❑ with Food Preparation — ❑Vending Machines Number of Units ❑ Retail Market- &lu Ire foot iijo _ ❑ wlMeal Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle -M i!••, _ _ Vehicle Type, ___ _ Color Regr,Awlion11 _ Lia;nselM ____ ------ Slicker# ❑ Mobile Food Prep Unit h1akr -_ -- ,- --Vehiclr_ Type — _ Color--` Regic.lr,i1!nn tt __ License tt Sticker N_ ❑ Temporary Food Facility -0.,l,",of operation from _ to — -- ---- ❑ Ice Plant ❑ Produce Stand ❑ Special Event--Dates of opc,ration ftnnl --- - to CFO ❑ A ZB DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Cuntainers in Multi-Head Unit _— CUPA ❑ Hazardous Materials Flushness Plan t 1(100) Number of chemicals _ ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility Hpzardows Waste Generator(2200)------—>-Tons Generated Per Year ❑ Tiered Permitting Facility----> OCA(2232) ❑ CE(2233,2234, 2235, 2231) ❑ 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 fomu ❑ Other CUPA Program _- HOUSING PROGRAM(240111 ❑ HoteUMotel --Niimbef of Units ❑ Jail or Exempt Institution -dumber of Units Employee Housing(2700)Use Employee HousinoalLabor 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-NPL/SEP 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(42001 ❑ Pumper VehicleRegistiation it _- _ License 0 i Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets —Number of Units SOLID WASTE PROGRAM(44001 I ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(o of u„is) ❑ Dumpslers> 20 cu yd too u,,,r.l ❑ FarmfRanch 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 gonerators Put7UC WATER SYSTEM PROGRAM(4600)Use PWS END 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM CONTACT PERSON t_ Day Ph 7_c9 117_- o L V1_ Night Ph ,,f& PROGRAM ELEMCNI /60" FEF Surcha ge FEi13Other FEE _ INSPECTOR - _ PERMIT VALID _V3(/2-+ to_ 3 _ ❑ Food Handier Check M ��. AMOUNT PAID Dale ^- r�---� INVOICE* p__ Cash REVIEWLDt3Y ACCOUNTING OFFICE Date Z 46402 034 FAASTERFILE RECORD I 1"ORMATION PINK 1!7113