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SAN JOAQUI d COUNTY ENIVIRONn' E,NTA- HEALTH DEPARTMENT <br /> �IASTERFILE RECORD RIFORI\IATION FOW <br /> ❑NeNvEH Program at ExistigPc\v EH Program and New Facility <br /> errant Record ID 0 3 ; � <br /> Facility Address /,0// F-. hvl>� S+- 1�Ylt�— #3 — <br /> (Please Check the appropriate description and specify size,number of units and perfinenf information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food handlers Course required: YEs ❑ NO ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machiaes—Number ofUnits <br /> ❑ Retail Illarket—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle---Make Vehicle Type Color <br /> Registration# License# Stinker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Ten,porary Food Facility—Dates of operation from to ❑ Ice Plant <br /> ❑ Slrecial F went —Dates of operation from to ❑Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A.Dairy, ❑ Grade B Dairy ❑Milli Dispeaser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IiAZARDOUS WASTE PROGRAIA(2200) t <br /> ❑ haz:ardous Waste Generator. Tons Generated Per Year ❑Recycle!EYernp(System(2299) <br /> ❑ CRT Offsite Hai dlers(2218) ❑ Silver Only(2222) l ❑Appliance Recyclers(2217) <br /> Tiered Fermitfing Facility ® Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pemait-By--Rule Fixed Unit ❑ Permit-By-Rule Household Iia—zirdous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number o f ASF <br /> UNDERGROUND STORAGE TANK(-UST)PROGRAM(2300)Use UST A and B Jrorzrrs <br /> I-IOUSIPIG FROG Al(2400) <br /> ❑ Hotenjotel Nurnber of Units ❑ jailor Exempt Institution Number of Units <br /> Eaeployee Ifousing(2700)Use F-,mpfvt•ee Ffarrs[[,&Laber Camp Appfieadarr Fomr <br /> SITE MITIGATION(2900) UNDERGROUND 9WECTIOId CONTROL(3000) <br /> ❑ EnAronmeetal Assessment ❑UST-CACP Site ❑Local IAV Cleanup Site. ❑NPLISEP Cteaaup Site ❑ UIC Site <br /> ❑ Abandoned hiV Site ❑ non-NPLISE]P Cleanup Site ❑RiVQCB Cleanup Site ❑iVater Quality Remediation Site <br /> RECRE86 i OONAL H EAU e C I GROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Nateral Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry F? Maximum number of birds ❑ Kennel <br /> TATTOO,BODY PIERCU4G,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Taftooing(4121) ❑ Body Piercing(4120) ❑ Permanent COsuietics(4122) <br /> LIQUID WASE PROGRA-M(4200) <br /> 1_J p umper Vehicle—Regis'uation;f License# Capacity vehicle-ft <br /> ❑ Pumper Pard ❑Package Treatment Plant ❑ Cliemical Toilets—Num ber of Units <br /> LOUD YVASTF PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> bA:1Vaste Tire Facility ❑ Compost Facility ❑ Process[Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsfers>20 cu yd—Number of Units ❑Farm/Raach Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility---❑ 2-10 ❑ 11 -60--❑ > 60 generators <br /> PU[3LIG 1,A(ATER SYSTO.,l PROGRAP,9(4600) Use PIf'SF'Ff£1 A6-42-003 t31rrc ApPhcariorl Form <br /> EMERGENCY HOTIFIc.4TtaN FCR i tris FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph bight Pb <br /> FD <br /> RoGILAAtEL}:HCNT ZI7� O FEE ElSurch3rgeFEE ❑ Other FLEEsrECTGR# 1126,20 1E-UHT VALID to ❑ Food Ilstndlcr <br /> ❑ Ch•xkr AMOUNT PAID DsG 111VOICE4 <br /> ❑ C�sh !'= '!L.'EDrt'e LCCii� Irn?�QFFI:E Date. ? IS, <br />