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17-Mov-2020 16:28 Private And Confidential. From:2093679996 p.9 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑New EH Pro ram at Existing Facility ❑New EH Pro ram and New Facifit Facility ID Q ; -1 Z95 Pro ram Record ID rjlf(p3��o Facility Address RVIOik 1W01C/A- (Please "(Please check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Sealing CapacitySquare Footage Food Handlers Course required: YtsIx NO ❑ ❑ Commissary ❑ Dry storage only ❑ with 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# D Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event---Dates of operation from to - CFO ❑ A IAB 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: ❑ CaIARP 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 loans ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution....Number of Units Employee Housing(2700)Use Employee Housing/Labor Camo 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-NPUSEP 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 An Facility-Sterilization(4121) ❑ Body Art Temp Event Co-ord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID 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(#ofunas) ❑ Dumpsters>20 cu yd(#of Units) ❑ FarmlRanch 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 ❑ 2-10 011 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form ttom-�. � ENI ENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGR CONTACTPERSON f% ti (ppt) .:3'?'l t k':2n, Day Ph •^� Night Ph tI—�• r- '%' 1 ' C�' % PROGRAM ELEMEryW I b-1 FEE 3i ❑ surChar aFEE ❑ Other FEE INSPECTOR# /0 (Jq PERMIT VALID 11-2-111 I w t0 12— 'TJI 2 ❑ Food Handler Check# 33 AMOUNT PAID 31 D — —Date 12I f 1 1 210 INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE L6 Date I :;t- 4"2-034 4a-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13 Received Time Nov. 11, 2020 3, 19PM No- 6468