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•- «�vovOi3a ENVIRONMENTAL HEALTH PAGE 02/03 SAN JOAQUIN COUNTY JVIRONMENTAL HEALTH DEPAF_MeNT MAST ERFILE RECORD INFORMATION FORM t New EH P rem at ExistingFacility ❑New EH program end New Facility DlEFCEFIV ED Facility ID I L4 Ll Program Record ID MAR -5 2012 Facility Address 7 3 1 (Please check the appropriate description and specify size, number ofunits and pertinent Information.) -/OEOFc�AQUINCOUNTV FOOD PROGRAM(1600) ,��lCfs 13 Restaurant: Seating Capacity_ Square Footage Food Handlers Course uirc : YEs❑ No [3 ❑ Commissary ❑ Dry storega only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market--Square footage ❑ with Meat Market only ❑ Multiple Departments[] Prepackaged Goods Only ❑ Mobile Food Vehicle-Make Vehicle Type Color Registration S License# Sticker# ❑ Mobile Food Prep Unit Make Vehicle Type Calor Registration# License# Sticker# ❑ Temporary Food Facility_Dates of operation from to ❑ lee Plant ❑ Special Event Dales of operation from to ❑ Produce Stand DAIRY PROGRAM(2000) Q Grade A Dalry ❑ Grade B Dalry ❑ Milk Dispenser-Number of Containers In Mufti-Head Unit COPA ❑ Slate Facility Surcharge(2399) J +&Aghr HAZARDOUS WASTE PROGRAM(2200) Hazardous Waste Generator-- Tons Generated Per Year _ ❑ Recycle/Exempt SyRterr (2299) CRT Offsite Handlers(2218) ---------❑ Silver Only(2222) ❑Appliance Recyclers(2217) Tlered Permitting Facility---- ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM (2300)Use UST A and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel--Number of Units ❑ U1 or Exempt Institution—Number of Units Employee Housing(2700)Use Employee Housirta/Labor Camp AM11cation Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑Abandoned HW Site ❑ non-NPL/SEP Cleanup Sita ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas al Facility_ ❑Pool ❑ spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROORAM(4000) ❑ Poultry Farm--Maximum number of birds O Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIAILI D_WASTE PROGRAM(4200) ❑ Pumper VehicleRegistra6on# License# Capacity Vehide# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets---Number of Units SOLID WQRDM(4400) ❑ Landfill ❑ Transfer Station ❑ AglCannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility 0 Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles to a urm) ❑ Dumpstels>20 Cu yd(a of Uwm) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) d Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -6o ❑ >60 generators P-UBLIC WATER SYSTEM PROGRAM(4000)Use PWS EHA 46-02-003 Blue Application Form EM ENCY N TI CATION FOR THIS F L AND/ PROGRAM CONTACT PERSON SR (1 010Wek /@�'] iV Day Ph-Z- I� Night Ph PROGRAM ELEMENT 2.27-0 FEE pPo nQ ❑ Surcharge FEE ❑ Other FEE INSPECTORS gy e46 PERMIT VALID ?� / 12 to 17,131 1 1 Z ❑ Food Handler ❑ CharA N Amousit PAID Date INVOICE Al 11 Cash REVIEWED BY au 12 ACOWNTWaI]FFICE Date 4 8-02-D34 MASTERFLE RECORD INFORMATION PINK 11/15107