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9_`-113-ct3131 J1.39Pt9 FPON TO 153OE17Elb � P.C14 <br /> !• • <br /> SAN JOAQUIN COUNTY{ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM(EH 00 691 <br /> ❑New EH Pro mat ExistSn Facilityi�New BH Pro ram and New Facility <br /> Tacthty ID "r Program'Record'ID ` <br /> FacilityAddress 't02b /ViEI4/1bA/ &6M i S i 0LANA/ <br /> (Please Check the appropriate description and specify size,number of units and Pertinent infonnatti n.) <br /> 'FOOD PROGRAM(1600) <br /> ❑Restaurant• Stating Capacity Square Footage Food Handlers Course required: Yrs❑ No❑ <br /> `'Ll Commissary ❑ Drystorage only ❑ with Food Preparation 17Vcnding Machines-Number of Units <br /> �❑ Retail Market.--Square footage ❑ with Meat Market only ❑ Mul4pie Departments ❑ Prepackaged Goods Only <br /> -'❑ Mobile Food Vchicic---Make i Vehicle Type Color <br /> Registration# License# Sticker# <br /> 13 Mobile Food Prep Uuit-Make VehidC Typc color <br /> Registration ! License# Sdckerit <br /> ❑Temporary Food Facility—Date-of operation from to ❑ Ice Plant <br /> ❑ Special Event - Dates of operation 'from " - to ❑ Produce stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Gradc'B Dairy ❑ Milk Disposer--Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(7100) <br /> ❑ Hazardous Waste Generator----Tons Generated Per Year <br /> Tiered Permitting Facility `7 Conditioually Authorized(CA) ❑ConditimtaHy Exempt(CE) <br /> b Permii-By-Rule Fixed.Unit 13 Permit-By-Rule Household Hazardous Waste <br /> ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)----Numb r of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use ffsrA and B forms <br /> HOUSING PROGRAM C2400) <br /> ❑ Hotemotef--.-Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Fddploycc Houslog(2700)Use Enminvcc HariSine/Lahor Caton Annlicarioll Form <br /> SI E MITIGATION(2900) UNDEROROUND INJECTION CONTROL(3000) <br /> Envlroamotttal Assessment El UST-CAP Site ❑,Local HW Cleanup Site 0 NPL/SEP Cleanup Site ❑ UIC Site <br /> . ❑ Abandoned I1W Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑Water Quality Remedlation Site <br /> RECREATIONAL HEALTH PROGRAM 0600) <br /> Number of Pools/Spas at Facility I ❑ Pool -❑Spa ❑Out of Service PooltSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ PoultryFarm—Maximum number of birds ❑ kennel <br /> TATTOO.,BODY PIERCING. PERMANE3iT COSMETIQ PROGRAM(4100) <br /> ❑Tattooing(4 121) Q Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle--Registration# License# Capacity - Vehicle# <br /> O Pumper Yard ❑ Package Treatment Plant ❑Chemical Toilets----Number of Units <br /> SOLIDWA$TE PROGRAM(4400) <br /> 13 Landfill 17 Transfer Station ❑Ag I Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility .❑,Process(Recycle Facility ❑ CIA Landfill Site <br /> 13 Refuse Vehicles-Number of Units,- ❑Dttmpsters>20:cu yd--Numbcrof Units 13 FarndRanch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4300) <br /> ❑ Primary Care ❑Acute Care 0;skilled Nursing. ❑Large Generator ❑Small Generator ❑ Limited Hauler <br /> ❑Traltskr station ❑Vctcrluary Clinic ❑ Commoti Storage Facility----I3 2-10------17 11 -60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIPS F.UOM 2 B/nc Annliaarian Fonu <br /> EMERC AcY NOTIPICATI N FOR"Tmis FACILITY YND O PRDC;RAM <br /> CONTACTPERSON ISN/14A 6LIVO-CA -1 Day J4 T Night Ph )h 7a'- 7 If07 <br /> PROGRAM�ELEMENT ' FEE '' '° Q Surcharge FEE .. 0 other FEE <br /> InsrttCroRB. EERMITYALID' � 'ao 13 Food Handler <br /> ❑Chock AMQUNT PAID ' Date - INVOICE <br /> GshRevtewr-,D uv . Aecotn+nrte Orplce; .... Date <br /> TOTRL P.04 <br />