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<br />PAYMENT <br />RECEIVED <br />APR 18 2023 <br />I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existin. Facilit <br />Facility ID F1CX:),27(,10 <br />Facility Address F17 5 ci <br /> <br />XNew EH Program and New Facility SAN JOAQUIN COUNTY <br />Program Record ID pRos-q-z37. I HEEANSHR <br />1K Ff)V1AERNI N <br />PA or/ c 4-1,v c/pC1(-1Z <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />90D PROGRAM (1600) <br />gl Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No IN <br />Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />Retail Market---Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type <br /> <br />Color <br />Registration # License # Sticker # <br />Mobile Food Prep Unit— Make Vehicle Type C Ior <br />Registration # License # Sticker 4 <br />Temporary Food Facility —Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event--Dates of operation from to 0 CFO 0A0B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />LI Hazardous Waste Generator (2200) >- Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel -----Number of Units 0 Jail or Exempt Institution —Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm------Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />LI Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />0 Pumper VehicleRegistration # License # Capacity Vehicle # <br />Pumper Yard D Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (z of u':s 0 Dumpsters > 20 cu yd (4 of Un Is) El Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 -60 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />- (CI t— Day Ph 2 C /0 3Night Ph2' t v; <br />Other FEE <br />0 Out of Service Pool/Spa 0 Natural Bathing Area <br />0 Kennel <br />0 Limited Hauler <br />0 > 60 generators <br />*ONTACT PERSON <br />PROGRAM ELEMENT <br />21I <br />INSPECTOR # <br />Check # <br />Cash <br />48-02-034 <br />1,23/13 <br />PERMIT VALI <br />AMOUNT PA1 <br />REVIEWED BY <br />CAt_14 <br />Food Handler <br />INVOICE # <br />Date <br />MASTERFILE RE OR2 INFORMATION PINK <br />ACCOUNTING OFFICE