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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM EH Proqram and New Facility ID L(v0Program Record ID I kcx.3-7 LCL Facility Address L• S 1 k (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) RECE►�ED SEP 2 8 2021 SAN JOAQUIN COUNTY HEALTH OE ARTM NT ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes ❑ 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 Primary Care ❑ Registration # License # Sticker # ❑ Temporary Food Facility --Dates of operation from to —El Ice Plant ElProduce Stand ElSpecial Event ---Dates of operation from to ElCFO ❑ A ❑ B 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, 22357 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 forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ HotellMotel ------ Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee HousinWLabor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB 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 PoollSpa ❑Natural Bathing Area 177 Kennel a TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) f- Body Arf Facility -Single Use k ❑ 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 ❑ Package Treatment Plant ❑ Landfill ❑Transfer Station 11 Capacity Vehicle # ElPumper Yard SOLID WASTE PROGRAM (4400) ❑ Chemical Toilets ----Number of Units CONTACT PROGRAM ELEMEaNT T�� FEE INSPECTOR # I, �S� PERMIT VAL ElCheck# '-tV (.55. A AMOUNT PAID ElCash REVIEWED BY Day Ph .33 ❑ Su to 3 D Date ACCOUNTING OFFICE ❑Other FEE ❑ Food Handler INVOICE#� Date !/3CY 413-02-034 /3.23��/ MNSTERFILE RECORwINFORMATION PINK 1/23/73 Ag/Cannery Waste Site ❑Sludge/Ash Site ❑ Waste Tire Facility 1:1 comp Facility ❑Process/Recycle Facility ❑CIA Landfill Site ❑ Refuse Vehicles (#of units) ❑ Dumpsters > 20 cu yd (#of Units) ❑ Farm/Ranch 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 ❑ 11-60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form CONTACT PROGRAM ELEMEaNT T�� FEE INSPECTOR # I, �S� PERMIT VAL ElCheck# '-tV (.55. A AMOUNT PAID ElCash REVIEWED BY Day Ph .33 ❑ Su to 3 D Date ACCOUNTING OFFICE ❑Other FEE ❑ Food Handler INVOICE#� Date !/3CY 413-02-034 /3.23��/ MNSTERFILE RECORwINFORMATION PINK 1/23/73