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PAYMENT FSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED MASTERFILE RECORD INFORMATION FORM DEC 19 2022 ❑ New EH Program at Existing Facility ❑New EH Pro(Iram and New Facility p SAN JOAQUIN COUNTY FacilityID �OZ-7 7 Pro ra Record ID MSq-0 EN iRoN�rs�v Facility Address _ _/3 L ___- 6W) S�{'F _ Gn (ctH E �E Y 443(C ;Please check the appropriate description and specify size number of units and pertinent information ) FOOD PROGRAM(1600) ❑ Restaurant Seating Capacity__ Square Footage Food Handlers Course required: YE�No ❑ ,,tj t'1.�Commissary 2'U storage only L�<ih Food Preparation ❑Vending Machines Number of Units _ _ Retail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle-Make_ __-- Vehicle Type - _ Color Registration# . _ _...__ _ License# _ __. Sticker# ❑ Mobile Food Prep Unit-Make_ Vehicle Type Color _ Registration# License# Sticker# ❑ Temporary Food Facility --Dates of operation from to _ ❑ Ice Plant ❑ Produce Stand ❑ Special Event-Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals. ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)---------->-Tons Generated Per Year ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE(2233. 2234,2235.2237) ❑ 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 forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ HoteVMotel---Number of Units ❑ Jail or Exempt Institution—Number of Units --._— Employee Housing(2700) Use Employee HousinglLabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPVSEP 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) LIOUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration # ___. License # _. _.. — Capacity Vehicle#_ - ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets---Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(x of unas) ❑ Dumpsters> 20 cu yd i#nl umsi ❑ Farm/Ranch 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 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form 1' / -EMERG C NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM / ,/ CONTACTPERSON_ ILJ-ni_ _ _—],- Day Ph y��y(may -r,�, Night Ph�lf_L X>% '4'3J PROGRAM ELEMENT FEE FEE ❑ Surchar e F E ❑ Other FEE INSPECTOR# �' r PERMIT VALID !2_ to ._., (Z.8�2.3 ❑ Food Handler ❑ Check# -_ AMouNTPAID 237.0 Date ( 'I 2- INVOICE# 4,377 67 ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date / 2.1 22 - 48 e2-034 MASTERFILE RECORD INFORMATION PINK 12113 J n /T � I'7 2D