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Jun 03 03 OB: 57a T�DEWAY CHEV 20239 2927 p. 3 <br /> ,II 05/2912003 08:04 209a„d3433 FIFTH FLOOR PAGE 03 <br /> SAN JOAQUTN COUNTY ENVXRONMENTAL HEALTH DIVISION <br /> j HASTERFILL RECORD INFORMATION FORM EH 00 6 <br /> ❑New SH Program at E ONOW EH Program and Nair Facility <br /> FdciH ID „1•' .tt,y, -ProrirnaccordID' <br /> Facility Address S33(p <br /> (PlGasc Check the appropriate description end specify fyC7, number of unite and pertinent information.); <br /> FOOD PROGRAM(1000) <br /> ❑Restaurant Seating Capadry ` $quare Footage Food,F1'4udle Courac required: ,Yes❑ No❑ <br /> ❑ Cottuaissary ❑Dry storage only 13 with Food Preparation ❑Veadya.Ma as of Units <br /> ❑Retail Market----Square faotagc 0 with Meat Market only ❑Multiple Do "Monts 0 Prepackaged Goods Orly <br /> ❑ Mobile Food VaMcle—Make Vehicle Type Color <br /> Rngistmti0np License ti Stieker# <br /> ❑Mobile Food Prep Unit-Make vehicle Type'' Color <br /> Rogisauion# Liconsa p Sticker# <br /> 0 Temporary Food Facility-•-Dates of operation from to ❑ Ica Plant <br /> ❑Special Event -Data of operation 'from to 0 Produccgtand <br /> DAIRY PROGRAM(2000) <br /> ❑Gra lc A Dairy 0 Grade B Dairy 0 Milk Dispenser—Number of Containers in Muld-Head Unit_ <br /> CuPA ❑State Facility Surcharge(2399) - �^ <br /> bIAZA DOIIS WASTE PROGRAM(2200) <br /> Hazardous Waste Generator — ----- -Tons Oenatated Per year <br /> Tiered Permitting Facility ❑Condidottally Authorized(CA) 0 04ition9ly Bxempt(CE) <br /> 5( <br /> LlPtttmh-By-Aute Fixed Unit 11Permit-ByRulo Household Hazardous Waste <br /> 5 ABOVEGROUND STORAGE TANK FACILITY CAM(2390)—NumborofAST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2900)Use U.ST Aeu•� d br ro <br /> HOUSING PROORAM(2400) <br /> C{Hatcl/Matel—Number of Units Jailor Exempt hPstitution--Number of Units <br /> Emplum Houvag(2700)Uaa Llhlitiom RdntbrrZ rber Crsern Atmiree'rion Fomr <br /> StTe MITIGATION(2900) UNDERGROUND iNJECTION Q RQLf3000) <br /> 0 Envirogmcatal Assessment Cl UST-CACP qitc 0 Local HW Cleanup Site P NPIJSEP Cleanup Site ❑UICSito <br /> ❑Ahandonod HW Site ❑1100-MPEJS�P Cleanup Sitc. ❑RWQCB Cleauup'Slto .1❑Water Quality Remediation Site <br /> RECREATIONAL HEALTN PROGRAM(3600) `, I 1 <br /> Number of PoolslSim at ❑Pool ❑spa �� <br /> pFacility_ p � ❑Out of Sen!lce PooPpa Cl Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> !� Poultry Farm—Maximum number of birds ❑Kmnol <br /> TATTOO B01IY PIERCING,PERMANENT COSMETI PROGR M(4100) <br /> Cl Tattooing(4121) ❑ Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> i <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑Pumper Vcbicic-Rcgistmtion# License# Capacity' Vehlele# , <br /> ❑Pumper Yard O Package Trcatmcnt Plant ❑Chomlc'al'putts I Numbcrofuaits 'I <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Laudfill ❑TraasfFtitution ❑AgI Cannery Waste Site 0 SludgelAsh Site <br /> !i ❑Waste Tire Facility ❑Compost Facility .❑Preet>9 Racyclo ltacllity ❑CIA LnRdfW Site <br /> Q Refuse Vdtidcs—Numbcr ofUaits 0 Dumpstcrs>20 cu yd—Number of Uaits ❑ Farm/Ranth Cleanup Sitc <br /> I NEDICAL WASTE PROGRAM(4500) ` <br /> 0 Primary Care 12 Acura Care 0 Skilled Nursing ❑Largo Generator ❑Small Generator 0 Limlted Hauler <br /> ❑Trausfer Station ❑Veterinary Clinic 0 Common Storage Facility—(3 10--12 it-60--Q <br /> >60 8onaratora <br /> PUBLIC WATER SYS3CEM PROGRAM(4600)USa PW$6rf0d69 Bhre Analiersrldn Foml <br /> EMERGIaNCY NOTIFICATION Fo Is FA-CUTY ANWQp PRRRRAM <br /> 1�� ; 6 q <br /> CONTACT PERSONDay Flt _1 Night Ph <br /> PROORANELEMPNTSurWatgcF 'r 13Other FZE' . <br /> -r-'^-r- <br /> lwsrt;Croft# to }. A ❑Food Handler _ <br /> ❑Check aAMOQNTPAID.`- Date '.t A . INVOICE# <br /> t1 6ash REvizwan SY i'ACOOONDNO OFFICE Date <br />