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12/19/2012 11:29 20910433 9JC EHD UNIT 3� RECEIVE SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT DEC 2 6 2012 MASTIERFILE RECORD INFORMATION FORM LI Now EH Proram atEMistingFacility NIeWEHPm ram andNow Faoillty ENVIRONMENT/ Facil' ID Pro ram Reaord ID577A HEALTH DEPARTMEN7 Facility Address 11s4 4SSQrv�Qt r<�nn� �?0Co� ct;, Cid 33 1 (Please check the appropriate description and spedfy size,numbe�nita and g9jUBenl information.) (1600) IJ ❑Restaurant: Sealing capacity_„ Square Footage Food Handlers Course required: Yea ❑ No ❑ ❑ Commissary ❑ Dry storage only Q with Food Preparation ❑Vending MachinesNumber of Units ❑ Retail Market--Square footege ❑with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only 0 Mobile Food Vehicle--Make Vehicle Type Color Registration License# Sticker# ❑ Mobile Food Prep Unit Make Vehicle Type color Registration# Licensee Sf Mr# _ [3TomPorery Food Facility-Dates of operation inxn to ❑Ice Plant ❑ $paolal Event Dates of operation from to ❑ Produce Stan R&KXEROGRAM(2000) ❑ Grade A Dalry ❑ Grade B Dairy ❑ Milk Oispansyr-Numberof Containers in Multi-Head Unit COPA �- LI Hazardous Materials Business Plan(1900) Number of chemicals: ❑CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility tHazardous Waste Generator(2200)---_--� Tons Generated Per Year 5Gv v H � tiered Permitting Facility-_....-o OCA(2232) ❑ CE(2233,2234,2235,2237) ❑PEIR(2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST)(2800) Number of ASTs ❑Underground Storage Tank Program(UST)(2300)Use[1ST A and 6 forms ❑Other CUPA Program HOUSING PROnRAr�. (2400) ❑ Hatel/Motsl--Number of Units ❑Jall or Exempt Insthation-"umbar of lite Employee Housing(2700)Use Emp(oy@&HaysinVLabor Ca HP Appircaffer Farm 3ITE MITIGATION(2aDp) UNDERGROUND INJECTION CONTROL(3000) ❑ Envrionmantal Agee sment ❑ UST-CAP Site d Local HW Cleanup Site ❑ NPIJSEP Cleanup Site ❑ uic$fit ❑ Abandoned HW Site Q non-NPL/SEP Cleanup Site ❑ RWOCB Cleanup Site R Water Quality Remedlatlon Sita RECREATIONAL HEALTH PROGRAM(3600) Number of Poo1sl5pas at Facility_ ❑ Poot Q Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Aroa VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm---Maximum number of birds Q Kennel TATTOO,IROQX PIERCING,PERMANENT COSMETIC PROO,R"(4100) ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(411.5) ❑ Body Art Facility-Single Use(4120) El Rudy Art Faclltty-Sterilization(4121) ❑ Body Art Temp Event Co-Ord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIOmO WASTE PR +R4!4(4200) ❑ Pumper VehleleRegistration# License# CapacityVehicle# ❑ Pumper Yard ❑ Package Treatment Plant 17 Chemical Toilets--Number of Units SOLID WASTE PROGRam(4400) ❑ Landfill 13 Transfer Station ❑Ag/Cannery Waste$ITE U SludgelAsh Site ❑Waste Tire Facility ❑ Compost Facility ❑ Pwcpw.c/Recycle Facility ❑ CIA Landfill Site CI Refuse Vehicles Por unit) Q Dumpsters>20 ou yd(sof uniw ____ 0 Farm/Ranch Cleanup Site K ICAL WASTE PROGRAM(4600) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic Q Common Storage Facility ❑2- 10 '❑ 11 -60 11 n 80 generators EUR it WAILS cvc7EM PRO[e2AM(4600)Use PWS RHD 11642-003Blue A licatron Fotm E ERA NGY NOTIFICATION FOR THisF CILITY/WDIORP CONTACT PERSON C&IVJ ^^ DsyPh '2 [-p0�'3 NightPn t{ PROGRAM ELEMENT Z FEEJ��_ r (7p ❑ Surcharge FEE ❑Other FEE INSPECTOR# PERMITVALIO_� 1 ( � tO 1101 0 !? ❑ Food Han � ❑ Chack g AMOUNT PA1 r� Date INVoICE# ❑ Cash REviCWED 9Y I\�1" )Z 1) )L/`ACcouNTmG OFFICE ,nate 12/17M2ag-0&aMASTERFILE RECOft INFORMATION PINK