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SAN JOAQUIN COUNTY�I`„VIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ED New EH Program at Existin Facility New qu Program and New Facility <br /> Facilit `ID C) l� ' Pro ram Record ID 53 G <br /> Facility Address ���`� ��,� �_n sAnr1 , (A q5 .2 0 S <br /> (Please Check the appropriate description.and specify size,number of units and pertinent information) <br /> FOOD PROGRAM(1600) <br /> S Footage <br /> Food Handlers Course required:. YEs❑ No ❑ <br /> E]Restaurant:Restaurant: Seating Capacity q g <br /> ❑ 11 withCommissary ® Dry storage only ith Food Preparation ❑'ending 14fachines—Number of Units <br /> El Retail 1lfarket—Square footage Elwith Meat Market only El Multiple Departments ❑ Prepackaged Goods Only <br /> Color <br /> El 1lfobile Food Vehicle--Make Vehicle Type Sticker# <br /> Registration# License# <br /> ® Vehicle Type Color Mobile Food Prep Unit—Make Sticker# <br /> Registration# License# <br /> ❑ Temporary Food Facility—Dates of operation from <br /> to ❑ Ice Plant <br /> ❑ <br /> El Produce Stand <br /> Special Event —Dates of operation from <br /> to <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser Number of Containers in Multi-Bead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS PROGRAM(2200)` i <br /> [I Hazardous Waste Genera tor.=— Tons Generated Per Year ❑ Recycle/Egcmpt Systern, <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) _ ❑ Appliance Recyclers(2217) <br /> Tiered Perruitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑Peanut-lay-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and.9 Tatars <br /> HOUSING PROGRAM(2400) <br /> ❑ Ilote3J1)fotel Number of Units 11 Jail or Exempt Institution Number of Units <br /> Employee I{oeasing(2700)Use Employee Il'orrsin�/Labar Camp APnficatran Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION coNTROL(3000) <br /> .[3 Environmental Assessment [IUST-CAPSite [I Local MV Cleanup Site ❑NPL/ <br /> . SEP Cleanup Site 11 UIC Site <br /> ❑ Abandoned IIAV Site [Inon-NPLISEP Cleanup Site 13RiVQCB Cleanup Site El Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(360,D) <br /> Number of pools/Spas at Facility. ❑P®ol ❑ Spa ❑ Out of Service Poollspa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ®Kennel <br /> ❑Poultry Farm Maximum number of birds <br /> TATTOO.BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ® Permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE pRoGRAM(4200) <br /> El pumper Vehicle—Registration# <br /> License# Capacity Vehicle# <br /> ❑ Pumper Pard ❑Package Treatment Plant- ❑ Chemical Toilets Number of Units <br /> SOLID YVASTE PROGRAM(4400) <br /> ® <br /> ❑A /CiVaste Site Sludge/Ash Site <br /> ® LagdGEl 1] Transfer Station g Cannery <br /> ,waste Tire Facility ❑ Compost facility ® ProcesslRecycle Facility <br /> ❑ CIA-Landfill Site <br /> ❑Refuse Vehicles—Number of Units _ ❑ Dumpsfers>20 cu yd—Number of Units ❑FarmfRanch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care El Acute Care ❑ Spilled Nursing ❑Large Generator l] Small Generator El Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--E] 7-i 0 ❑ I1-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PiVSEffD d6-02-003 Flue Annl«a6Gt1 Form <br /> EMERGENCY NOTIFICATION FOR THIs FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON_ _ Day Ph Night Ph <br /> i <br /> PROGIZ-01 ELEMENT kA rm, FEE: ❑ SurcliargeFEE '. ❑ other FEE <br /> INSPF_CTOPA __ PERMITVALID . 7I toEl ��5-0�j ❑ Food Handler <br /> �IYIour-rr -mo 'Date 1ClVOICEI€ __ _-- <br /> ch��a f� — -- <br /> gE -7L--7 f 1 ACCOLrdTlldG�FFIC6 <br /> ❑ C'ash iLTVIE�VF.D BY /_� <br />