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PAYMVED SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM MAY 2 Now EH Pro ram el Exlstin Facility❑New EH Pro rem and New Facllit 5 2021 Fac ID Program Record ID Sq 14 A U/N COU II FacilityAddress 1�-y,(�� , NEAL'r' O N&jR OE TV (Please chock the appropdale description and specify size number of units and pertinent Information.) NT FOOD PROGRAM (1600) []Restaurant Sealing Capacity_ Square Footage Food Handlers Course required: Yea ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market—Square footage ❑ w/Meal Market only ❑ Multiple Departments ❑ Prepackaged Goods Only .Mobile Food Vehicle -Make GS Tra t3 Vehicle Type LTi F Color YELL,-0� Registration #F165 C, Tt zt 6lHbrnw 5- License # 7tmjJ 166 3 1 Sticker # ❑ Mobile Food Prep Unit- Make Vehicle Type Color Registration # License # Slicker # ❑ Temporary Food Facility -Dates of operation from to ❑ Ice Plant ❑ Produce Stand ❑ Special Event -Dates of operation from to ❑CFO 13AOB 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 (22361 ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST Aand B forms ❑ 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 Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWOCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility _ ❑ Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm --Maximum number of birds_ ❑ Spa ❑ Out of Service PoouSpa ❑ Natural Bathing Area ❑ Kennel TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art FacilltySingle 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 VehicleReglstration # License If Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets —Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ AglCannery Waste Site ❑ SludgelAsh Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles per Unna) ❑ Dmnpslers > 20 cu yd (if of uNm) ❑ FamVRanch 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 112 - 10 011-60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02.003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACTPERSON -\Ai2£ Aye- 2-S4— -Day Ph40H-50n'41523 Night Ph b'•tlr PROGRAM ELEMENT __ �\ \-J FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# ♦ ,`♦o♦(e PERMIT AL -2Ln'T21 l0 12.-3\ ❑Food Handler ❑ Check # AMOUNT PAID V Dale S INVOICE # ❑Cash REVIEWED BY ACCOUNTING OFFICE / Dale 11 '',73)11 Can ' 4 l �81a72 LS