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PAYMENT RECEIVED SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MAY 19 2023 MASTERFILE RECORD INFORMATION FORM ❑New EH Program at Existing Facility []New EH Program and New Facility SAN JOAQUIN COUNTY ENVIRONMENTAL Facility (o$ Program Record ID QOS HEAL�� q?TMENT Facility Address 2088 Cr. wa�r� r i✓14� cti CA S 33 — S�u'6tti�`S (Please check the appropriate description and specify size,number of units and pertinent Information.) RfP� ROGRAM(1600) 6d Rea staurant: Seating Capacity Square Footage Food Handlers Course required: YES❑ No❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units W Retail Market—Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only If 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 ❑ Ice Plant❑ Produce Stand ❑ Special Event—Dates of operation from to 66CFO ❑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(2233.2234,2235,2237) ❑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) ❑ HotelfMotel—Number of Units ❑ Jail or Exempt Institution--Number of Units Employee Housing(2700)Use Employee Nousina/Labor Camp Application Form SITE MfTIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑Abandoned HW Site ❑ non-NPUSEP 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) 11 — Poultry Farm---Maximum number of birds 11 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 Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(a of units) ❑ Dumpsters>20 cu yd(a of Un,ts) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care El Skilled Nursing 13 Large Generator 13 Small Generator EI Limited Hauler ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 011 -6o ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS E W 46-02-003 Blue App/lca Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON 00"C4 a P Day Ph 207 S3 7203 Night Ph ,rt7A?tr PROGRAM ELEMENT 1624 FEE 3�55 / ❑ Surchar e F E 11 Other FEE INSPECTOR# 8788 PERMIT VALID `'/i 2 t0 S 3 Z ❑ Food Handler ❑Check# AMOUNT PAI Date s INVOICE# 3 S I G 17 ❑Cash REVIEWED BY ACCOUNTING OFFICE Date S AUISTERFILE RECORD NFORMATION PINK 48-02-034 1123/13 Scanned with CamScanner