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r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM PA y� AA,, ❑ NeW EH Program at Existing Facility ONew EH Program and New Fact— Program ac Facili ID Pro ram Record ID R `470161? AJIG Fac�lity Address 10(17DKAXOn Dr. ADLvIeAn 2 , -Zr S�v,ogQ Os 2021 (Please check the appropriate description and specify size,number of units and pertinent information.vi,,,�R�UM COUN yD FNT ry FOOD�ROGRAM(1600) M7.�, ,t'" ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs aCr)No 13❑ Commissary ❑ Dry storage only ❑ with Food Preparation [Wending 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 ❑ ICF Plant 13Produce Stand ❑ Special Event—Dates of operation from to rz�!`CFO,CA ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit.— CUP ❑ Hazardous Materials Business Plan(1900) Number of chemicals: ❑ Ca�IARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Haardous Waste Generator(2200)—>-Tons Generated Per Year ❑ Tiered Permitting Facility—> ❑ CA(2232) ❑ CE(2233,2234,2235,2237) ❑ PBR(2231) ❑ PBR HHW(2236) ❑ Atioveground Storage Tank Facility(AST)(2600) Number of ASTs ❑ Underground Storage Tank Program(UST)(2300)Use UST A and B fortes ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel—Number of Units ❑ Jail or Exempt Institution—Number of Un is Employee Housing(2700)Use Employee Housing&abor 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 ❑ 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(4126) ❑ Body Art Facility-Sterilization(4121) ❑ Body Art Temp Event Coord (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) El Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of Un'ds) ❑ Dumpsters>20 cu yd(#or units) ❑ FamdRanch 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 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600)Use PWS EHD 46-02-003 Blue Atop/icadon Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON SrrG Day PhnLq' /a -V 9rD Night Ph 204-&'1D - 09/0 PROGRAM ELEMENT ( 4,O$ FEE ❑ Surchar FEES 13 Other FEE INSPECTOR# PERMIT VALI / 1 tokZ -3 z/ Z ❑ Food Handler ❑ Check# AMOUNT PAID IS b Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date Z 48-02-034 /�/� n 2��/ MASTERFILE RECORD INF RMATION PINK 1/23/13 l