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SAN JOAQUIN COUNTY EN :ONMENTAI, ITEAILTI-1 DEPART1. NT <br />MASTERFILE RECORD INFORMATION FORM <br />tiNew EH Program at Existing Facility <br /> DNew Eli Program and New Facility <br />Facility ID r-4-- OD D ,Scv ProEram Record ID SD-7112— <br />Facility Address ---;-- 7 4-- _rif \Jo Li S I j , A- C -PilmL <br />(Please Check the appropriate decription and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No rii <br />D Commissary 0 Dry storage only 0 with Food Preparation DVending Machines -Number of Units <br />El Retail Market —Square footage 0 with Meat Market only CI Multiple Departments 0 Prepackaged Goods Only <br />!::st Mobile Food Vehicle---Make -4.,, .2.-.0(7c .c t Vehicle Type - F/42-1-LC C- Color y c ,_,, <br />Registration # (X-E- F (---- 9 61 (e' 511:iense # -5-cCe "7 C,-, b.J.- Sticker # <br />Registration if <br />Color 0 Mobile Food Prep Unit-Make Vehicle Type <br />0 Temporary Food Facility --Dates of operation <br />El Special Event -Dates of operation from to <br />DAIRY PROGRAM (2000) <br />ID Grade A Dairy 0 Grade B Dairy <br />CUPA CI State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />0 Hazardous Waste Generator —Tons Generated Per Year <br />IA CRT Offsite Handlers (2218) 0 Silver Only (2222) _ <br />Tiered Permitting Facility 0 Conditionally Authorized (CA) <br />0 Permit-By-Rule Fixed Unit <br />0 ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br />D Hotel/Motel —Number of Units 0 Jail or Exempt Institution —Number of Units <br />Employee Housing (2700) Use Employee HousineLabor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />0 Environmental Assessment CI UST-CAP Site 0 Local IlW Cleanup Site. 0 NPUSEP Cleanup Site 0 UIC site <br />0 Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQC13 Cleanup Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 rcol 0 Spa 0 Out of Service Pool/Spa <br />VECTOR CONTROL PROGRAM (4000) <br />0 Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />0 Tattooing (4121) 0 Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />0 Pumper Vehicle-Registration # License if Capacity Vehicle if <br />0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets—Number of Units <br />SOLID WASTE PROGRAM (4400) <br />0 Landfill 0 Transfer Station 0 Ag / Cannery Waste Site El Sludge/Ash Site <br />0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />0 Refuse Vehicles -Number of Units 0 Dumpsters >20 cu yd —Number of Units 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />0 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />ID Transfer Station 0 Veterinary Clinic 0 Common Storage Facility----0 2 - 10 —0 11 - 60 --0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PH'S ElID 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY ANDfOR PROGRAM <br />CONTACT PERSON D k,/ E-- (.2)(2.-A--L6---E._ Day Ph -, 2 'f - ':‘ /' Night Ph <br />/ <br />License # Sticker if <br />from to El Ice Plant <br />0 Produce Stand <br />0 Milk Dispenser—Number of Containers in Multi-Head Unit <br /> 0 Recycle / Exempt System (2299) <br />0 Appliance Recyclers (2217) <br />Cl Conditionally Exempt (CE) <br />0 Permit-By-Rule Household Hazardous Waste <br />0 Water Quality Remediation Site <br />0 Natural Bathing Area <br />0 Kennel <br />0 Permanent Cosmetics (4122) <br />PROGRAM ELEMENT (, FEE .0' -Ci'D CI Surcharge FEE • 0 Other FEE <br />INSPECTOR it ":0" 3 4'7 `1 PERMIT VALID . to 0 Food handler <br />D Check # AMOUNT PAID Date INVOICE if <br />0 Cash REVIEWED BY ACCOUNTING OFFICE Date <br />Macterfile Record Pink