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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existing Facil ow EH Pr ram and New Fa <br />Facility ID �5,46D2-1�12 Program Record ID /SDS 7.�/ <br />Facility Address�-ZG.,�1` ��r G� 9s op' <br />(Please check the appropriate description and specify 2A& number of wriftand p Alnent Information,) <br />F�QD PR06ji1 (1600) <br />❑ Restaurant: Seating Capacity Square Footage �� Food Handlers Course required; Yles ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />❑ Retail Market ---Square footage ❑ with Meet Market only CI Multiple DepartmentsCp-16'repackaged Goods Only <br />❑ Mobile Food Vehicle–Make Vehicle Type Color <br />Registration # License # Sticker # <br />1"I Mobile Food Prep unit Make Vehicle Type _ <br />Registration # License ! Sticker # <br />13 Temporary Food Facility –Dates of operation from to <br />❑ Special Event Dates of operation from to <br />DAIRY PROGRAM (2000) <br />r-1 Is <br />Color <br />_ ❑ Ice Plant <br />❑ Produce Stand <br />rade A Dalry ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />❑ Hazardous Waste Generator ----------Tons Generated Per Year ❑ ReryclelExampt System (2299) <br />❑ CRT Offsite Handlers (2218) -----------❑ Silver Only (2222) ❑ Appliance Recycles (2217) <br />Tiered Permitting Facility -----....--_-....❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />Ll Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste <br />❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use U_STA end B forms <br />HOUSING-PROPRAM (2400) <br />❑ Hotel/Motel -----Number of Units Ci Jail or Exempt Institution ---Number of Units <br />Employee Housing (2700) Use Emn/ovee Housinp/Labor Cams Anal t! Form <br />RITE MITIGATION (2900)VNQERGjR0L1NQ1NjECTI0N CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site 0 Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remedlatlon $Its <br />(3600) <br />Number of Pools/Spas at Facility[]pool ❑ Spa <br />(4000) <br />❑ Poultry Farm- ---Maximum number of birds <br />TATTOCIAODYPIERGIN . Dl~RMANENT ^nC�•-Mq ear.-. � (4 100) <br />❑ Tattooing (4121) ❑ Body Piercing (4120) <br />LIQUID WASTE FROGMM (4200) <br />❑ Pumper Vehicl R Ist <br />❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />e eg ration tt License # Capacity Vehicle # <br />13Pumper Yard 11Package Treatment Plant ❑ Chemical Toilets ---Number of Units <br />SOLIDAS PROGRAM (4400) <br />O Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Faculty ❑ Compost Facility ❑ Process/Recycle Facility C] CIA Landfill Site <br />❑ Refuse Vehicles 0 of unite) ❑ Dumpsters > 20 cu yd (# of unita) ❑ Farm/Ranch Cleanup Site <br />W (4500) <br />❑ Primary Care Cl Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limped Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 011-60 ❑ > 60 generators <br />PUBLIC WATERI=M PRO -GRAM, (4600) Use PWS EHA 46-0&003 Blue AUftodon Form <br />CONTACT PERSON 1.�C <br />PROGRAM ELEMENT j11� PE .OZ) <br />INSPECTOR# L;— PERMIT VALID 2 ZDIL <br />❑ Check # AMOUNT PAID <br />❑ Cash REVIEWED sy <br />48.02.034 <br />11/15/07 <br />Day Ph ,'� W7 <br />❑ Surch rge EE <br />to / / , 3 <br />Date <br />ACCOUNTING OFFICE <br />Received Tlme Dec. 14. 2012 1.23PM \1o.3124 <br />Night Ph <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE * 23LFI I <br />Date /- <br />MARTERFILE RECORD INFORMATION PINK <br />