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New EH Program at Existing Facility ONew EH Program and New Facility <br />Facility ID rilo,n 7_79 Program Record ID 'Pk <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility Address Address <br />(Please check the appropriate description <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />ED Commissary 0 Dry storage only 0 with Food Preparation <br />2_ Lk 0 . 0\'\ (pot- SAN JOAQUIN COUNTY <br />and specify size, number of units and perti=nformation.) HEALTH DEPARTMENT <br />ENVIRONMENTAL <br />Food Handlers Course required: YES 0 No 0 <br />I:Vending Machines Number of Units <br />PAYMENT <br />RECEIVED RECEIVED <br />DEC 0 1 2023 <br />Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only , <br />IE Mobile Food Vehicle --Make fc-ci <br />1• 1 <br />Vehicle Type Ti)- (- ei 4 Cc- Color rt")^ ( ti <br />Registration # / <br />g <br />)9,3 3 0 <br />ll r419 <br />License # CZ n-9-7- Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <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 />Hazardous Materials Business Plan (1900) Number of chemicals: <br />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-NPUSEP 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 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br /> <br />0 Kennel <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 />Pumper VehicleRegistration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br /> <br />o Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility <br /> O Process/Recycle Facility <br />Refuse Vehicles of of Units) <br /> <br />o Dumpsters > 20 cu yd (4 of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 <br /> <br />0 > 60 generators <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 L.l9 5 3 o <br />PROGRAM ELEMENT \\(:)S FEE <br /> <br />0 Surcharge FEE 0 Other FEE <br />INSPECTOR # P PERMIT VALID V2. - - 23 to \2 - - 2_ H 0 Food Handler <br />3 0 Check # akej. (+ AMOUNT PAID 02.3-1.0 Date 1/ <br />Cash REVIEWED BY ACCOUNTING OFFICE <br />INVOICE # Date / 277262_ <br />El <br />1/23/13 <br />to 0 Ice Plant 0 Produce Stand <br />to OCF0 0A0B <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />Day Ph Night Ph <br />48-02-034 6A,(24 i7ig3(57/2__ MASTERFILE RECOR INFORMATION PINK