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CI New EH Program at Existing Facilit 1:1New EH Program and New Facilit Facility ID Aao2ZIS1 Program Record ID riK09-0 - MASTERFILE RE PROGRAM ELEMENT /k•2 3 FEE INSPECTOR # 2 ? PERMIT VALID CI Check # AMOUNT PAID Cash REVIEWED BY r CI Other FEE CI Food Handler INVOICE # 3 a37 Date ORI INFORMATION PINK El Surcha ge F to ‘5? 3 Date ACCOUNTING OFFICE SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM Facility Facility Address e2J (------- Yo se.44-2ile A 71--e'cl-0— \ (Please check the appropriate description and specify size, number of units and pertinent information.) ty iNijg1Q1J/N Co FO9D PROGRAM (1600) PA t rL , _ ONA4 . 'V A ,..pivr y 17 pi elP.App.n.71.1;41. 0 Restaurant: Seating Capacity / 2- Square Footage Food Handlers Course required: YES CI ri o ' urE-Nr. CI Commissary CI Dry storage only I=1 with Food Preparation OVending Machines Number of Units CI Retail Market----Square footage 0 w/Meat Market only CI Multiple Departments 0 Prepackaged Goods Only Mobile Food Vehicle --Make Vehicle Type Color Registration # License # Sticker # CI Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # CI Temporary Food Facility --Dates of operation from to 0 Ice Plant CI Produce Stand CI Special Event---Dates of operation from to 0 CFO 0 A CI B DAIRY PROGRAM (2000) CI Grade A Dairy CI Grade B Dairy CI Milk Dispenser-Number of Containers in Multi-Head Unit CUPA CI Hazardous Materials Business Plan (1900) Number of chemicals: El CalARP Program 0 Program 1 Facility 0 Program 2 Facility CI Program 3 Facility CI Hazardous Waste Generator (2200) > Tons Generated Per Year CI Tiered Permitting Facility > CI CA (2232) 0 CE (2233, 2234, 2235, 2237) CI PBR (2231) El PBR HHW (2236) CI Aboveground Storage Tank Facility (AST) (2800) Number of ASTs Underground Storage Tank Program (UST) (2300) Use UST A and B forms ID Other CUPA Program HOUSING PROGRAM (2400) El Hotel/Motel Number of Units CI Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site CI NPL/SEP Cleanup Site 0 UIC Site Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site CI Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility El Pool CI Spa CI Out of Service Pool/Spa CI Natural Bathing Area VECTOR CONTROL PROGRAM (4000) Cl Poultry Farm Maximum number of birds 1:1 Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) CI Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) 12 Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) CI Pumper Vehicle Registration # Pumper Yard CI Package Treatment Plant SOLID WASTE PROGRAM (4400) CI Landfill 0 Transfer Station 0 Ag/Cannery Waste Site CI Sludge/Ash Site CI Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility I=1 CIA Landfill Site I=1 Refuse Vehicles (# of units) El Dumpsters > 20 cu yd (# of Units) CI Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) CI Primary Care D Acute Care CI Skilled Nursing 0 Large Generator CI Small Generator CI Limited Hauler Transfer Station 0 Veterinary Clinic 0 Common Storage Facility El 2 - 10 El 11 - 60 0 > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON PAYm Nt sAN APR °3 2024 License # Capacity Vehicle # CI Chemical Toilets ----Number of Units c.'7" Day Ph /C / 2 Night Ph --)C) 171 /0 — 2 / 1/23/13