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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT t MASTERFILE RECORD INFORMATION FORM , ❑New EH Program at Existing Facility AfNew EH Pr ram and New Facility Facili 10 D Pr rare Record ID O Facility Address l8 Z2 X / w C.k - i0(j �5 33U (Please check the appropriate description and scecify sae,number of units and pertinent information i FOOD PROGRAM(1600) ❑Restaurant Seating Capacity Square Footage Food Handlers Course required: Yes or No❑ ❑ Commissary ❑ Dry,storage only ❑ with Food Preparation ❑Vending Machines N_;, D of U.nrs ❑ Retail Market—Square footage ❑with Meat Market only ❑ M:1!tpue DepartrnertOP•epaokaged Goods On�y LI Mobile Food Vehlcle-Make Ve�:c!e Type C.0:0v Registration# License# SbckL-X ❑ Mobile Food Prep Unit Mane Vehicle Type COQ Registrabon 9-- Lcese Stcker t ❑ Temporary Food Facility-Dates of operation from to ❑ Ice Plant ❑ Special Event Dates of ceeration from to ❑ Produce Stand DAIRY PROGRAM IZ0001 ❑ Gracie A Dairy ❑ Grade 6 Dairy u italic Dispenser-hun-i_er of Conizy ers CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardo#js Wast?Generator Tnns(-__r%erets-d PPr Year O Recyck-WEX-7t Sy-,ztr'rn;229 ❑ CRT Of'--,re Handlers i2218i ❑Silver Only(2222) ❑ApcaaRex!rps:22•'' Tiered Permitting Facility ❑ CorWiConaliy Authcrtred(CA) ❑(.0 A^2'.i EX-0 -C. C= C1Permn-By-Rule Foced Und ❑ Pe:. y-R_e H-ose:oc Haza cs'.%��e ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) M_!—^a-AST UNDERGROUND STORAGE TANK iUST)PROGRAM(2300)Use USTA a-d B forms HOUSING PROGRAM 12400) ❑ Hole„•...:.a:--Nixnber acw EX;,-pl.�.�.....w Employav Housing(2700)Use Employee Housing/Labor Camp Application✓=crrr' SITE MITIGATION i29W) 3CO-Z E! Environmental Assessment ElUST-CAPSite v ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ U1C Sri-- E im❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation S= RECREATIONAL HEALTH PROGRAM i?bCOi cf Pocfs;Spas a;Fac!rty ❑ Pool ❑ Spa ❑ Out of Service PooLSpa ❑ Natural Ba-d:ing:Area VECTOR CONTROi-PROGRAM i:vire) ❑ Poultry Farm—Maxrrurr number of t-rds ❑ Kennel TATTOO 500Y PIERCING PERMANENT COSMETIC PROGRAM!4100) ❑ Tattooina r4.2' ❑ Body Piercing(41201 ❑ Permanent Cosmetics;4'22) UQUID WASTE PROGRAM'.4200) ❑ Pumper Vehicle R :ssaton# Lcerse Cc ^r Ve?,:Cie ❑ Pumper Yard ❑ Package Treatment Ptant ❑ Chemical Toilets SOUO WASTE PROGRAM'44CC: ❑ Landfill ❑ Transfer Station ❑ Ag.Cannery Waste Site -' Sludge Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process.Recycie Facility _' CiA Landfill S.-he ❑ RefuSa VB7nc;t o�.a _-5 Cu yii S:x MEDICAL WASTE PROGRAM 145GO, ❑ Pnmary Care O Acute Care O Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Lrnitd Hauler ❑ Trangfgr Station ❑ Vntonnary Clint O COrnn+Cxi Stnr?ry FarJity O ❑ LI > PUBLIC WATER SYSTEM PROG RAJA 4=5000 Ua PWS EHD 46-02-003 Blue ApplicaDon =_ ELERGEt.C'r NOTIF CAT1004 SCA T;,_s FACILITY ati C_•PROGR" �s _ CONTACT PERSON Dal, r ZS- - &�,c" PROGRAM ELEMENT F ❑surcha F ❑ Other FEE INSPECTOR# PERWT\1 to Jr ❑ Food Handler J� i?ivv:�c S iCJ ihet7c a'I AiiOi)I(T PAW _ D.'tc 0 CashR=vc+a�;ev ACCOLtereaG OFFrs Date 4&02_c34 WAS'r---L_Q_'-Z sC i1ES�lit'.R ANK