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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility <br /> ENew EH Program and New Facility <br />Facility ID Program Record ID <br /> <br />PROGRAM ELEMENT 3611 FEE 212.25 <br />INSPECTOR # <br />Check If AMOUNT PAID <br />CI Cash <br />0 Food Handler <br />17 INVOICE # <br />Date 7/1) i/2$ <br />4589 PERMIT VALID <br />REVIEWED BY <br />0 Surchar e F E CI Other FEE <br />to <br />2— Z Date <br /> <br />ACCOUNTING OFFICE ( <br />0 Milk Dispenser -Number of Containers in Multi-Head Unit <br />Tons Generated Per Year <br />CI Silver Only (2222) <br />Conditionally Authorized (CA) <br />Permit-By-Rule Fixed Unit <br />CI Recycle/Exempt System (2299) <br />1=1 Appliance Recyclers (2217) <br />Conditionally Exempt (CE) <br />Permit-By-Rule Household Hazardous Waste <br />Facility Address 5317 IRONWOOD AVE TRACY CA 95377 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity <br />CI Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make Vehicle Type <br />PAYME'NT RE-CE•IVE D <br />S APR 29 2024 <br />AN JOA QUIN COUNTY EN VIRONMEN TA I_ HEA <br />LTI-1 DEPARTMENT <br />Square Footage <br />0 with Food Preparation <br />0 with Meat Market only <br />Food Handlers Course required: YES 0 No CI <br />OVending Machines Number of Units <br />0 Multiple Departments0 Prepackaged Goods Only <br />Color <br />Registration # License # Sticker # <br />Mobile Food Prep Unit Make Vehicle Type <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to <br />Special Event Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy <br />CUPA CI State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />Hazardous Waste Generator <br />CI CRT Offsite Handlers (2218) <br />Tiered Permitting Facility <br />ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <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 NPLJSEP 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 1 IE 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 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Tattooing (4121) 0 Body Piercing (4120) 0 Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License If 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 0 Ag/Cannery Waste Site <br />0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (tr of Units) 0 Dumpsters > 20 cu yd (4 of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing CI Large Generator CI Small Generator CI Limited Hauler <br />Transfer Station CI Veterinary Clinic 0 Common Storage Facility CI 2 - 10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Lauren Morte Day Ph 925-886-1492 Night Ph <br />48-02-034 <br />11/15/07 <br />Paying for 3/4 of the yr. <br />MASTERFILE RECORD INFORMATION PINK <br />Color <br />CI Ice Plant <br />0 Produce Stand <br />Sludge/Ash Site <br />CIA Landfill Site <br />CI Farm/Ranch Cleanup Site <br />0 11 - 60 CI >60 generators