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Vehicle Type Color <br />License # Sticker # <br />Vehicle Type INUA0 V f\ Color \\0(1%-\-f, <br />License # "PAI Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />to <br />0 CFO LI A 0 B <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />LI Dumpsters > 20 Cu yd (4 of Units) <br />El Sludge/Ash Site <br />0 CIA Landfill Site <br />1:1 Farm/Ranch Cleanup Site <br />PAY <br />PROGRAM ELEMENT (614_ FEE <br />INsP CTOR # PERMIT VALID <br />Check # AMOUNT PAID <br />Cash REVIEWED BY <br />0 Surcharge FE Other FE THDEP4RT47 . <br />Food Handler <br />INVOICE # <br />Date <br />to <br />Date <br />ACCOUNTING OFFICE 2, <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />28 2024 <br />SAN JOAQUI <br />New EH Program at Existing Facility ,ONew EH Program and New Facility <br />Facility ID rill(10,2—SOF2j Program Record ID ii,o,c*gq4 <br />Facility Address 1.4- -gO AT) c'k710-4-% <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 1:1 <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 <br />Registration # <br />IP Mobile Food Prep Unit-- Make chi-A <br />Registration # 3 L. <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <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 />0 Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />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 />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 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 0 Out of Service Pool/Spa El Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />El Poultry Farm Maximum number of birds <br /> <br />0 Kennel <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 />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 />Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (it of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator <br /> <br />0 Small Generator <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 <br /> <br />O 11 - 60 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON N r u ;12..v( \CaS Day Ph 1> c-ck ci2-t.,3 Night Ph c\\.r.r\, <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />48-02-034 MASTERFILE R ORD FORMATION PINK <br />1/23/13