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PAy1VED SAN JOAQUIN COUNTY ENVIRONMENTAL AI;ALTFI DIVISION R� MASTzRFQ,E RECORD(INFORMATION FORM EH 00 6 8 ZOOS yt Eg2 . . ❑New EH Pro ram of Czislhl Facility lis New EH Program' and New Faeilil f COUNT ,..,.,.« ._.- c;a<xrfir; yy ..Y mqu,y.X<tv a r r SAN AOZNSEOGES .. Ficihl ID • . ;xt + r ;yt Pro rain Record ID1" p JO � Ett`nA NM NTq�HEP��Hp1�S10N Facility Address a80 SW:: Cl-l� Avt, M ahe CGl nA 95-3 3 � (Please Check the appropriate description and specify aizc•number or mens and itcriincnt In form aIioit FOOD PROGRAM(1600) 0 Restaurant: Stating Capacity Square Foolago 7 Lr Food Handlers Course remnrcdt VPs❑ No❑ ^. ❑ Comnhlssary ❑ Drystorage only ❑'with Food Preparation []Vending Machines—Number of Units ❑ Refill Markel----Square footage ❑ with Mcat Market only ❑ Mulliple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Veldcle---Makc Vchicic Type - I Color .. Registration 11 License it Slicker 0 13 Nubile Food Prcp Uuit--Makc VchicicTypc Color Registration 11 License 0 Sticker 0 0 Temporary Food Facility----Dates of operation from to ❑ Ice Plant ❑ Special Event - Dales of operation from to ❑ Product Slant DAIRY PROGRAM (2000) ❑ Cradc A Dairy ❑ Grade B Dairy ❑ Milk Dispenser--Number or Containers in Multi-Head Unit CUP A ❑Stale Factllly Surcharge(2399)' HAZARDOUS WASTE PROGRAM(2200) - ❑ IIazardous Waste Generator-------------=---Tons Generated Pcr Ycdr Ti6rcd Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Pcmiil-By-Rule Fixed Unit ❑ Pcrmil-Ey-Rule Household hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Numbcr of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and lI to HOUSING PROGRAM(2400) - ❑ Ilotel/Molel-----Numbcr of Units ❑Jail or Exempt Institution—Number or Units Employee llousing(2700) We EronPoPee Rortsinr/Laanr Crtnm Annliertlirtn Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL0000) ❑ Environmental Assrssmcut ❑ UST-CAT Site ❑ Local IiW Cleanup Site ❑ NPLJSEP Cleanup Site ❑ UIC site ❑ Abandoned IIW Site ❑ non-NPLISEP Cleanup Site, ❑RWQCB Cleanup Site ❑ Water Qualify Remcdlation Site RECREATIONAL HEALTH PROGRAM(3600) Numbcr of Pools1Spas.al Facility ❑ Pool ❑Spi ❑ Out arScrvicc Pool/Spa ❑ Natural Balking Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Fenn—Maximum number of birds ❑ Kcmtcl TATTOO, BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tallooln¢(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) _ LIQUID WASTE PROGRAM(4200) I ❑ Pumper Vddele--Registration 11 License#- Capacity • Vehicle ❑ Puruper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of Units SOLID WASTE PROGRAM(4400) ' ❑ Landfill ❑ Transfcr,5tation• ❑Ag Cannery Waste Site ❑SludgdAsh Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Fadllty ❑ CIA Landfill Site ❑ Refuse Vehicles--Number or Units ❑ Dumpsters>20 cu yd—Number or Units ❑ Farm/Rancll Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing b Large Generator ❑ Small Generator ❑ Limited Ilauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—❑ 2- I O----❑ It-60.----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)UaePWSCN0069Dlue AaaUm(iorr Form - _ EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM - CONTACT PERSON I Day Ph jX 2Z-066D NIghI Ph __�S�'/rzC� II ,'LEf�.•,r. .. Il1t0CILlM1'; MENT_� (IEE dx ❑'SurchargaFggh .. ..` ❑ Other FEE INSPtCTOIIN. L21 CItMITVALID 03 ❑ Food Handler ytt'.Chockp� 39 AMOUNT PAID` t)3r2v1"�]NVOICCN (Cash RCVItWCD DY - 4le«, ACCOUNnNOrDPPICCn DaIC '� Z EI I wog PINK POIiM.Joc .^