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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM :1 RE YNjFN ❑New EH Program at Exlstin Far-111tv `dNew EH Pr ram and New FacilityC` `/� Fac(Ilt ID � Z�l�f Program Record ID OR O Facility Address_, )05 �OEST 11 4� mEa -rnAcf CA A53�� Sqn/� �8 ?024 (Please check the appropriate description and specify�[�,number of units and Pertinent InformationyEq�T RAN/ FOOD PRON COV GRAM(1600) H SEA ENrq NrY ❑ Restaurant Seating Capacity Square Footage Food Handlers Course required YES Q`lu47E] ❑ Commissary ❑ Dry storage only ❑ with Food Preparation []Vending Machines Number of Units &]�Retall Market—Square footage ❑ w/Meat Market only ❑ Multiple Departments 0-Prepackaged Goods Only ❑ Mobile Food Vehicle—Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# El Temporary Food Facility—Dates of operation from Sticker# to ❑ Ice Plant❑ Produce Stand ❑ Special Event—Dates of operation from to CFO ❑ A ❑ B DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit ❑ Hazardous Materials Business Plan(1900) Number of chemicals: _ ❑ CalARP 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 8 forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel—Number of Units ❑ Jail or Exempt Institution---Number of Units Employee Housing(2700)Use Emplovee Nouslnp/Labor Came Annllcatlon Form $ITE MITIGATION(2900) -UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP 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) ❑ Poultry Farm—Maximum number of birds TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Kennel ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art Facility-Single 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# ❑ Pumper Yard -- Capacity Vehicle#___ p ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units SOLID WASTE PROGRAM(4400) _ ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ Sludge/Ash Site ❑ Refuse Vehicles(#of units) ❑ CIA Landfill Site ❑ Dumpsters>20 cu yd(#or units) ❑ FarnVRanch Cleanup MEDICAL WASTE PROGRAM(4500) p site ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 ❑ Small Generator ❑ Limited Hauler 10 PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue A licatlon Form ❑ 11 60 ❑ >60 generators MEROEN Y No CATION FOR THIS FACILITY ANDlOR PROGRAM CONTACT PERSON w\G. -, Day Ph tee` . PROGRAM ELEMENT , _ Might Ph �— FEE Z - ❑ Surcharge Fee ❑ Other FEE INSPECTOR# ��1. PERMIT VALID to AMOUNT PAI C Check a 2 ❑ Food Handler D` �-75,d�_? Date 2 ---- Il Cash REVIEWED BY INVOICE# d8.02.03A ACCOUNTING OFFICE Date 1/23/1 MASTERFILE R ORD FOR TION PINK �,032