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PAYMENT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED <br />MASTERFILE RECORD INFORMATION FORM OC g <br />ew EH Proaram at Existina Facility sw EH Prooram and New Facilitv 1 3 2021 <br />Facilitv ID P1 <br />Facility Address kvf' " j � -%U XYUc )T JUY I <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Temporary Food Facility --Dates of operation from to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to ❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit _ <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200) -------- 2 ->-Tons <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ HotellMotel ------ Number of Units ❑ 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 ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds ❑ Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) �// <br />El Body Art Practitioner Reg (4110) El Mechanical DSPS Notification (4115) LKBody Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care -❑ Acute Care El Skilled Nursing El Large Generator El Small Generator El Limited <br />Pumper Vehicle Reg}stration # <br />License # Capacity <br />Generated Per Year <br />❑ <br />Pumper Yard ❑Package <br />Treatment Plant ❑Chemical Toilets <br />---Number of Units <br />❑ <br />Tiered Permitting <br />Facility -------> <br />❑ <br />CA (2232) <br />❑ CE (2233, 2234, 2235, <br />2237) <br />❑ PBR (2231) <br />❑ <br />PER 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 />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ HotellMotel ------ Number of Units ❑ 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 ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds ❑ Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) �// <br />El Body Art Practitioner Reg (4110) El Mechanical DSPS Notification (4115) LKBody Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care -❑ Acute Care El Skilled Nursing El Large Generator El Small Generator El Limited <br />Pumper Vehicle Reg}stration # <br />License # Capacity <br />Vehicle # <br />❑ <br />Pumper Yard ❑Package <br />Treatment Plant ❑Chemical Toilets <br />---Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ <br />Landfill ❑ Transfer Station <br />❑ Ag/Cannery Waste Site <br />❑ <br />Sludge/Ash Site <br />❑ <br />Waste Tire Facility ❑ Compost Facility <br />❑ Process/Recycle Facility <br />❑ <br />CIA Landfill Site <br />❑ <br />Refuse Vehicles (#of units) <br />❑ Dumpsters > 20 cu yd (#of units) <br />❑ <br />Farm/Ranch Cleanup Site <br />Hauler <br />Lj Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 -60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />�1( , EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Y1M�`M� Y-` nink LS Day Ph 8rXt - 3. I&t Ph 209' ctot <br />PROGRAM ELEMENT 611 ,2() FE07 3:T E J ❑ SurCh/a_r a FE El Other FEE <br />INSPECTOR#_ 9�1j�_ PERMIT VALID 0 to (� �i El Food <br />Handler <br />❑ Check #—IIW//1 �� AMOUNT PAID 2 06 Date INVOICE# 3G <br />1:1 Cash REVIEWED BY ACCOUNTING OFFICE Date / 3 <br />202-034 ^0 MASTERFILE RECORD INF <br />1/ <br />1/23/13 f/y :�(e/33174=77 <br />