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SAN JOAQUIN COUNTY ENVIRONMENTAL MALTA DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ Ne\K EHiPro ram aGExistin rF.aciti ❑New EH Pro ram and:NeW Facill Faciii >ID:. `� Pro ram Record ID' ` .OS Facfllfytlddress 1t-i(Jta �. :: it;�,r��.tz ie;(ra�Q . Mcf�<:bl�tarin ,�� .�� a5'��( (Please Check theappropdate description:and specify size,numherof un6 and pertinent information.) ' :F000 P OGRAM(1600) I � SqurFooage ood Handlers Corse rre oRestaurant . Seating'Capacty ❑ Commissary ❑1]rystorage'only ❑�siiiffiFaodPreparalion f❑Vending-Machines Number ofUnits ❑ Retail Market---Square footage. ❑.w/Mbat Market;only ;O MAIiie Departments Q Prepackaged Goads Only ' ❑ Mobile Food Vehicle--Make ` : : -- Vehiole'Type ` -': Color Registration# Llcedse.# . Sticker# ❑ Mobile Food Prep Unit-Make Vehl6ja:typeColor Registration# Llcense# Sticker# ❑ Te*6rary Food Facility--bates of Operation from to ❑ Its Plant❑ Produce Stand :;.❑ Spepial Event---Dates b f operation from _.: to : 1:1CFO:fJ A ❑ B DAIRY PROGRAM(2000) -❑ Grade q:Dairy ElGrade B Dairy El Milk Dispenser-Number of Containers in Multi-Head Unit_ ❑ Hazardous Materials Business Plan (1900) Number.ofcherrocals: `.::❑ CaIARP Program ❑ Progratti 1 Facility . ❑ Program 2 Facility ❑ Program 3 Facility .. .:' ❑ Hazardous Waste Generator(2200)------> Tons Generated Per Year - r❑ Tlered:Permitting:Facility— -? -1:1.CA-(2232) :.:❑ CE(2233,2Z34,,2235.22.37) El PER(2231) ❑ PBRHHW,(2236) - ❑Aboveground Storage Tank Facility{AST).(2800) Nu nbei of ASTs La Underground Storage Tank Program(UST)(2$00) Use USIA and 8 forms 13 Other COPA Program �.HOUSING'PROGRAM(2400) - ❑ Hotel)MoW------Number of Units ❑ Ja0 or Exempt institution--Number ofUn is Employee:Housing{2700) Use Employes HousinalLaborCamo ADolication Form . SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL.(3000) ❑ Environmental-Assessment 13 UST-CAP Site El Local HW:Cleanup;Site Q NPUSEP Cleanup Site ❑ UIC Site - ❑ Abandoned HW Site EInon=NPUSEP Cleanup Site ❑.RWQC13 Cleanup Site' ❑Water Quality Remediation Site '.:RE(jREATIONAGHEALTH PROGRAM.(3800) : :- Numberof Pools/Spas at Facility :.::_ 0.Pool ❑ Spe ❑ out Service Pool/Spa ❑ Natural Bathing Area ::VECTOR CONTROLPROGRAM:(4000 -- :. 0 Poultry'Farm-------Maximum number of birds ❑,Kennet :TATTOO.BODY PIERCING-PERMANENT COSMETIC PROGRAM (4100) ;' :r❑ Body Art Practitionar Reg(4116) ❑ Mechanical OSPS Notification (4115) ❑ Body;ArtPacility:Single.Use(4120) ❑ Body Art Facility-Sterilization (4121) .❑ Body Art Temp Event Co-ord (4130) ❑ Body Art Temp Event Mobile Facility (4131) .LIQUID WASTE PROGRAM(4200) - - - - ' -❑ Pumper VehicleRegistretion# ' �License# .`Capacity - Vehicle:# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of Units SOLID WASTE PROGRAM (4400) O Landfill . ❑ Transfer Station. . . ❑ Ag/Cannery Waste Site - ❑ Sludge/Ash Slte ❑ Waste:Tire Facility ❑ Compost facility ❑ ProcesslRecycte Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(z of units) :❑Dumpsters 5 20 cu yd(#or Units) : `i7 Farm/Ranch Cleanup Site . MEDICAL WASTE PROGRAM(4500)',. O Primary Care 1 : O Acute Care ❑ Skilled Nursing ❑ Large Generator.. : ❑ Small Geilera#Di ❑ Limited Hauler ❑ TransferStatton OVeterinary Clinic ❑ COMM onStorage Facility _❑.2'-'10' ❑ 11x60 .•i❑'y'BOgenerattlrs - ;.PUBLIC WATER SYSTEM PROGRAM (4600)UsePINS EHD 48.02-003 B/DeADplicafion FOmi EMERGENCY NOTIFICATIONFOR THIS FAC OhIILITY AND)OR PROGRAM CTACTPERSON�t�-OcXS, JUvic�:' ('e.c�tY DaNlghtPp: PROGRAM;ELEMENT \O - FEE ❑ SurchargeFEE ❑ Other FEE INSPECTOR:# PERMITjj VALID to ❑ Food Handfer ❑ Crieck# -A MOUNT .IPAID ' .Date .. INVOICE# ❑ Cash :.:REVIEWED SY • {„..: ACCOUNTING OFFICE Date g 9 - `, MASTERFILE RECORD INFORMATION PINK