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SAN JOAQUIN COUNTY ErORRONMTNTAL HEALTH DT'V>1SI 11LASTERFILE RECORD INFORMATION FORM EH 00 69 ❑Nm EH Program$t Existing Facility []New Ell Program and New FACill Facill ID f :.1E'r" •Aiu.Record ID Facility Address 315 S. Center street (please Check the appropriate description and speciry sim number of ugitj and pertinent infot nItlon.) FOOT} PRCWRAM(1600) 1 ❑Restaurant: Seating Capacity Square Footage Food Handlers Course rcgpired: YF3 ❑ Iva ❑ ❑ Coammniasary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units ❑ Retail Market---Square footage_ ❑ with Meat Market only ❑ Multiple Dopartmentr ❑ Prepackaged Goods Only ❑ Mobile Fwd Vehicle--Make Vehicle Type Color Registration# Licrose# Sticker# ❑ Mobile Food Prep[Snit—Make Vehicle Type Color Registration#f Liunse i! Sticker# © Temporary Food Facility----Dates of operation from to ❑ Ice Plant 1 ❑ Spaciai Rvent - Dates of operation from to ❑ Produce Stand PAiRY PROG.Bm(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk I]tcpenser—Number of Containers in Multi-Bead Unit CUP g ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) 17 H"ardous Waste Generator---- --_------ ---Tons Generated Per Yens Tiered Permitting Facility ❑ Conditionally Authori2ed(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Housebold Hamdous Waste- ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)----Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use LISTA and B Lrm_s HO SING PROGRAM(2400) ❑ llotel/Motd Number of Units ❑ Jail or Ezcmpt Institution---Number of Unitc l_ Employee tionsing(2700) Us*Empin,yea]5Tou r/L.Ybar Cam Appiicatioe Fonn ' 31TE MIT1OwTWN(2900) MIADERGROLMWNJEC7I0t+I CONfiRQL(3000) t Environment2l Assessment Q UST-CAP Site ❑ Local HNV Cleanup Site ❑ OL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALT14 PROGRAM(3600) Number of PooWSpas at Facility ❑ Pool d Spa ❑ Out of Service Fool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farms Maximum number of birds ❑ Kennel TATTQQ. BODY PIERCING PEFtMAHENT coD GTIG ritOOP-Am(4 100) ❑ Tattooing(4121) ❑ Bony Piercing(4120) L1 Permanent Cosmetics(4122) 1 UID WMTE PRO ttAM(4200) 0 Pumper Vehicle—Registration# License# Capacity Vehicle h ❑ Pumper Yard ❑ Package Treatment Plant ❑ Cbernical Toilets- --Number of Units SOLI)WASTE PROOMM(4400) ❑ Landfill ❑ Transfer Station ❑ AZ/Cannery Waste Site ❑ SlodCeAsh Site O Waste Tire Ficwty L3 Compost Facility © Process/Recycle Facility ❑ CIA Landfill Site 1 ❑ Recuse Vehicltn--Number of Units ❑ Dumpsters>20 cu yd---Number of Units ❑ Farm/Ranch Cleanup Site EDtCAL,WAM PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility---❑ 2- I o=----❑ 11 -60--❑ ?60 generators PUBLIC t+}IfATE'.R SYSTEM PROGRAM(4600) Use PWS 4FT0049 Blue Apnlicalinx Form EMERc;Ncy NOTIFICAnON FOR TMs FACILITY ANWOR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT_ FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMIT VALID to ❑ Food Handier ❑ Cheek# AMOUNT PAID Date INVOICE# ❑ Cash RsviEWEu BY Aecot c OfmcE Date EH W0 PINK FORM.doc RcV-07107,"