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2020-06-23 09:46 KP OPTICAL SERVICES 9164785360 >> P 3/5 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT I MASTERFILE RECORD INFORMATION FORM PAYMEfV T' ❑ New EH Program at Exi.sting Facility ❑New EH Program and New Faclllt Facility ID 0021's-INE-0021's-INE- RECE'V Program Record ID Q; ED Facility Address VV- oI (�v i ` 5;� (d JUL 0 , Z020 (Please check the appropriate descrlption and specify size, number of units and pertinent Information.)FiE N JOAQNMEcTA�Ty FOOD PROGRAM(1600) fg� TA ❑ Restaurant, Seating Capacity Square Footage Food Handlers Course required: Yes ❑T 6N ❑ 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# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant ❑ Produce Stand ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROQRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit GUPA ❑ 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 El Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employae Housing/Labor Camp Applic on 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-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIQNAL 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) X 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) 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 (#or units) ❑ Dumpsters> 20 cu yd (#or units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Cllnlc ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46.02-003 Blue Appli a "on Farm CONTACT PERSON 1, ��ME Day Ph ITYAND/oR PRO �AN ght Ph PROGRAM ELEMENT N I I C FEE ❑ Surcha ge F E ❑ Other FEE INSPECTOR# q5' 3G PERMIT VALID 7 ZD77�� to ,30 2 Ll Food Handler ❑ Check# AMOUNT PAI .Ov Date 7 INVOICE �— ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date –1131Z,? 48-02-034 1 MASTERFILE REC RD INFORMAL ION PINK