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Facility Address Address '75 63 <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 0 No 0 <br />CI Commissary Cl Dry storage only 0 with Food Preparation 0Vending Machines Number of Units <br />CI Retail Market----Square footage 0 w/Meat Market only CI Multiple Departments 0 Prepackaged Goods Only <br />0 Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />CI Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # <br />CI Temporary Food Facility --Dates of operation from to <br />CI Special Evpnt---Dates of operation from to <br />e 04-e/v. <br />DAIRY PROGRAM 3i)0 O) <br />Grade A Dairy CI Grade B Dairy <br />CUPA <br />CI Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program 0 Program 1 Facility CI Program 2 Facility CI Program 3 Facility <br />CI Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Cl Tiered Permitting Facility > CI CA (2232) 0 CE (2233, 2234, 2235, 2237) CI PBR (2231) 0 PBR HHW (2236) <br />CI Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />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 />CI Environmental Assessment CI UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site CI UIC Site <br />CI Abandoned HW Site El non-NPLJSEP Cleanup Site CI RWQCB Cleanup Site 1:1 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility CI Pool <br />VECTOR CONTROL PROGRAM (4000) <br />CI 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) CI Body Art Facility-Single Use (4120) <br />CI Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event Mobile Facility (4131) <br />0 Spa 0 Out of Service Pool/Spa <br />CI Milk Dispenser-Number of Containers in Multi-Head Unit <br />Sticker # <br /> 0 Ice Plant CI Produce Stand <br />0 CFO CI A 0 B <br />CI Natural Bathing Area <br />CI Kennel <br />PAYMENT <br />NOV 1 8 <br />RECEIVED <br />2023 <br />..1 <br />SAN JOAQUIN <br />H <br />COUNTY __ENVIRONMENTAL <br />EALTH DEPARTMENT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility <br /> <br />*New EH Program and New Facility <br />Facility ID r48a;-71,5-7 <br /> <br />Program Record ID <br />q9 PERMIT VALID <br />AMOUNT PAID <br />PROGRAM ELEMENT FEE El Surcha 0 Other FEE FE <br />Ar/ MASTERFILE RE 0 D INFORMATION PINK 4 -02-034 <br />1/ 3/13 <br />ACCOUNTING OFFICE <br />W2-3 to <br />Ob Date <br />INSPECTOR # <br />CI Check # <br />Cash <br />CI Food Handler <br />23 INVOICE #,?.?? 15-2 <br />Date / / 23 <br />3 <br />REVIEWED BY <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper VehicleRegistration # <br />CI Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />CI Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care CI Acute Care CI Skilled <br />CI Transfer Station CI Veterinary Clinic <br /> Capacity Vehicle # <br />CI Chemical Toilets ----Number of Units <br />El Ag/Cannery Waste Site <br />CI Process/Recycle Facility <br />El Dumpsters > 20 cu yd (# of Units) <br />CI Sludge/Ash Site <br />CI CIA Landfill Site <br />CI Farm/Ranch Cleanup Site <br />Nursing CI Large Generator CI Small Generator CI Limited Hauler <br />0 Common Storage Facility 0 2 - 10 CI 11 - 60 CI > 60 generators <br />License # <br />CI Package Treatment Plant <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 />CONTACT PERSON Day Ph Night Ph