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SAN J"OAQUIN COUNITY ENVIRONMENTAL HEAD` H DETA1zTMENT <br /> _ MASTER ILE RE CORD INFO1UNIATION F0101 <br /> 9—New Eli Program at Existing Facility _ ❑Ncw EIl Program and New Facility_ <br /> I+acilif} IIS _� � �_—_ I'��ra[rr I?ecoid II) R-oS3S"4a-a <br /> Facility Address :77:7110 dt)pf,,-A_ )Dc <br /> (Please Check the appropriate deseriptioa and specify sue=ilunil)4 of units and pertinent information.) <br /> l=006 PROGRAM(tGOU) <br /> El Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES El NO ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑`'endiag Machines—Numbcr of Units <br /> ❑ Retail Market—Square footage ❑ -with l4cat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mbile Food Vehicle---h'Iake Vehicle Type Color <br /> Registration# License& Sticker# <br /> ❑ mobile Food Prep Uait—Make Vehicle Type Color <br /> Registration# License 9 Sticker� <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plaut <br /> ❑ Special rycnt —Dates of operatian from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ P,filk Dispeascr--Numbcr of Containct s in Multi-Head Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> IiA'ZARDOUS WASTE PROGRAiiI(2200) i <br /> ❑ hazardous-Waste Generator-- T ons Generated Per Year ❑ Recycle I Efenrpt System(2299) <br /> ❑ CRT Offsite Handlers (2219) ❑ Silver Only(2222) ❑ Appliance Re-cyclers(2217) <br /> Tiered Per;aitting Facility ❑ Coaditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑ Perrtut-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numbcr of AST <br /> UNDERGROUND STORAGE T Al1I_(UST)PRO GRAM(23 00)Use UST A and F forms <br /> HOUSING PROGRAM(2400) <br /> ❑ IIotel/blotel Number of Units ❑ ➢ail or Eyernpt Institution--Number of Units <br /> Eatployee Housitag(27N) Use FnrrrloF,cc Housiti&Labor Camp Applicariorr Form <br /> SITE MITIGATION(2900) U -JDERGROUHD 1r-IJ=CTIWrI CONTROL(3000) <br /> ❑ EnAronrncatal Assessment ❑ �JST-CAI'Site ❑ Local 11W Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br /> El Abandoned IM'Site El nou-NI'L/SEI'Cleanup Site ❑f:4i`QCB Cleanup Site ❑ Water Quality Remediatioe Site. <br /> RECREATIONAL HEALTH PROGRAM(3G00) <br /> Number of Pools/Spas at Facility ❑ ii gaol ❑ Spa ❑ Out of Service I'ool/Spa ❑ Natural Bathing Arca <br /> VECTOR-CONTROL PROGRAM(4000) <br /> ❑Poultry'Fara, 1\fatimum number of birds ❑ Kcaael <br /> TAT-100, BODY PIERCING,PERNTAHEI•I s•COSMET9C PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ rerruanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—RegiAntion rt, License # Capacity Vehicle ff _ <br /> ❑ Pumper Yard ❑ Pacl;.age T'reatmeat Plant- ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ 'Transfer Station ❑ Ag/Canner-y Waste Sitc ❑ Sludge/Ash Site <br /> ;. Yaste'Tire Facility ❑ Compost F'acili(y ❑ 1'rocess[Recyce Facility ❑ CIA Landfill Site <br /> ❑ Refuse N'eliMes—Number of Units ❑ Dumpstcrs>20 cu yd --dumber of Units ❑ F-irrar/R_nch Cleanup Site <br /> P.IFDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator 1-1 Sural!Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑Veterinary Cieic ❑ f'arawon Storage Facility---D 2- 10- ❑ 1I -60 ----❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) flscPWSF,If1) /6-02-003 RlitcApplicarion!Fart <br /> rttarcErscr H0TNrtCAr60:s t'oR,Tms FACILITY ArdDIOR PROGRAMI <br /> CON TACC Pb:f:SOI t Day Ni Night Ph <br /> l'ITOGR?�f L:C I;hY�iti T � FEe _ —_❑ Surcharge Fur: ' t ❑ Other F't;.r <br /> dIVSPLC-1 ❑ Food handler <br /> ❑ Clr_c}.r; -- <br /> r� -- ---- ------ ----- - — <br /> l.JC-IJI S'J=`'lF_`ar[>tt7 i,i_rt.tri:rilb3(IrFp:F — I_/;iC - — <br />