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Le <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />at <br />and New <br />1 REMENT <br />C <br />EIVED <br />Facility ID -F, DZ� Program Record ID OS�,O/L I JUL 16 2020 <br />Facility Address Z6o2- W tr` L-OXI! tCA 9SN1Q <br />JOAQUINCOUNTY <br />(Please check the appropriate description and specify size, number of units and pertinent information.) HEALTH DEPARTMENT <br />VIRONMENTAL <br />FOOD PROGRAM (1600) <br />"Restaurant: Seating capacity <br />_a— Square Footage /,SOV Food Handlers Course required: YEA No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />❑ Retail Market—Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle -Make <br />Vehicle Type <br />Color <br />Registration # <br />License # <br />Sticker # — <br />❑ Mobile Food Prep Unit- Make <br />Vehicle Type <br />Color — <br />Registration # <br />License # <br />Sticker # _ <br />❑ Temporary Food Facility -Dates of operation from <br />to <br />❑ Ice Plant <br />❑ Special Event—Dates of operation from <br />to _ <br />[]CFO ❑ A ❑ B <br />Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />ff Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaLARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200) --->-Tons Generated Per Year <br />❑ Tiered Permitting Facility —> OCA(2232) ❑ CE (2233, 2234, 2235, 2237) ❑PBR (2231) ❑ 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 ❑ Jail or Exempt Institution --Number of Units <br />Employee Housing (2700) Use Employee Housina/labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPIJSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility_ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Fame—Maximum number of birds_ <br />❑ Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body ArtTemp Event Coord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper VehicleRegistration# License# Capacity Vehicle# <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Tollets ---Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles 1# of unite) ❑ Dumpsters > 20 cu yd (# or Units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 -10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4000) Use PWS EHD 46-02-003 Blue Apoffcarlon Form <br />CONTACT PERSON GL EgA—:� <br />Day Ph59(-295-9 9f- 7 Night Ph <br />PROGRAM ELEMENT FE.3 ID. ❑ Surchar e F 13 Other FEE <br />INSPECTOR# n1Qg PERMITVALID !�O t0 / Z C1 Food Handler <br />❑ Check # PCZ ` AMOUNT PAID .S , 0V Date 7 INVOICE # .3 3 <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE Date ' 7- <br />48-02-034 / / MASTERFILE RECOKD INFORMATION PINK <br />1/23/13 <br />