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SAN JOAQUIN COVNTSt ENVIILONMENTAL HEALTH DErARTMEN'Ir FlE'CEIVED <br /> M 451ERFILE RBCORDINFORMATION FORM <br /> ❑New EH PFOVAM at EXiStiftj Facility []New EN proVarn and New Fade FEB 10 2011 <br /> Facili ID .t Pro mmRecordED B <br /> OFFICEOFEMERGNCYSER <br /> Facility Address �l� E MERGE <br /> ( Pia � Specify NCYSERVICEfi <br /> Please Check thea appropriate destri nerd number of VOWS asci petlinrnlisformatlan.) <br /> OOO�M(16M) <br /> sack Poota Food Handler Course requiired: Yrs❑ No Q <br /> ❑Aeriannul' Stating Capacity Sq ge ) <br /> ❑ Commimry Q Dryaorage only ❑with Food Preparation ❑Yent[mg Machines NuDdra of Units <br /> ❑Retail Market----Square footage ❑with Meat Market only ❑Multiple Dep uh=ts ❑Prepackaged Goods Only <br /> ❑ Mobile Food Vehick—Make Vchide Type color <br /> Registration N _ Lieensc N Sticker# <br /> ❑Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration N Lkcnse N Sticker N <br /> 13Temporary Food Facility—Dates of opeeitim from to ❑Ice Plant <br /> ❑Special Erent --Dates ofoperation Som to_ <br /> . p Pradott sans <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dalry UGrade Bbatrl ❑ ki <br /> MilkDitpeoxr--llasnlxr of in Mu -Head Unit <br /> -CUPA ❑SUte Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) tt S 7299 <br /> (Z Hazardous en <br /> Waste Ccrntor�� ❑Recycle/Exempt 3TCm <br /> ns <br /> —ToGcnccated Per Year 2B�1 — ( ) <br /> 13CRT Offsite Handlers(221 O ❑Silver Only(2222) LlAppliance Recycles(2217) <br /> Tiered Pcranittiag Faex7ity ❑Conditionally Authorized(CA) ❑Conditionally Exclept(CE) <br /> ❑Permit-By-Risk Fixed Unit ❑Pnndt-13y Rule Hooschold H-mdous Waste <br /> ❑ABOVEGROUND STORAGE TANK FACUX"(AST)(2390) Nmsber of AST <br /> UNDERGROUND STORAGE TANK(US)PROGRAM(2300)Ux US! d erns <br /> HOUSING PROGRAM(2400) <br /> Q HotdM*td---Number of Units [11.0 ar Eaempt Institution— Naan6�OfUoits <br /> Empw7ae if a asiae(2700)Use - owav=r/Lab o r Cave,tppfiteo?oa Fenn <br /> SITE MjqTjGATlOt4(2900) - UNOERGROUND INJECTION COHIROI{3000) <br /> ❑EaytronmaUl Assessment E]UST-CAPSite ❑fwrat HW Cleanup Site. ❑NPLISEP Cleanup Site ❑111C Sift <br /> Q Abandoned HW Site ❑ ann44PUSEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> 1cECREAMONAL N£ALTH PROGRAM(7600) <br /> NumberofPooIdSpaS at Facility ❑P"I ❑Spa 11Oot of Service Poovspa Q Natural Balhiag Arca <br /> VECTOR.CONTROLPROGRAM(4000) <br /> ❑Poultry Farm---Maximum number of birds ❑Kenoel <br /> TATTOO BODY PIERCING PERMANENT COSMI,l6 PROGRAM(4100) ❑Permanent CosoMia(4122) <br /> ❑Tattooing(412 1) ❑Body Pierviog(4120) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑Pamptr Vehlde—Rc9i7rati0n N License N Capacd7 Vchide N <br /> []Pumper yard ❑Pscloge Treatment Plant- ❑Chemical Toilets—Numt-of Units <br /> SOLID WASTEPUOGRAM(4400) <br /> ❑ Landfill ❑Trxaster Station ❑Ag I Cannery Waste Site ❑SludgefAsh Site <br /> ❑Waste Tire Facility ❑Compost Facility ❑Process/Recycle Facility ❑ CIALsadfdl Site <br /> ❑Refnx Vehicles—Number of Units ❑Oompstm>10 ea yd—Nomba of Units ❑ParmMAIrch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑Skilled Norsing ❑7argt Generator ❑Small Geaerator ❑ Unsitcd hauler <br /> ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--❑2-10—Q 11-60_0>60 generators <br /> PUDLIC WATER SYSTEM PROGRAM(4600)Us PN'SEf/A 46-02-003 BIne Aenr' Form <br /> EMERGENCY NOTIFICAT/DN FOR?NIS FACILITY ANDCOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FEC [I Surcharge FEE ❑Otber FEE <br /> IrvsrseroR N - 74w PEMM VAUD 2011 tom/Y ❑Food Handler <br /> ❑Cj k0 AMOUNT PAID Date INVOICE# <br /> ❑G-n REvvtmL uy Accor Nc Orrice Date v <br /> u..r-F.b R�rnra Ri.i- <br />