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c <br /> SAN JOAQUIN COUNTY ENVIRONti1ENTAL HEALTH DEPAIn'MEN`I' <br /> MASTERFILE RECORD INFORMATION FOIST. <br /> ❑New Eli Program at Existing Facility w L•11 Program and N'ew Facility— <br /> Facility ID OD P—LIO �2So Pryor,rant Record 1D 5,35(o O C7 <br /> Facility Address Z * 90Z, 11reAc�,�_ <br /> (Please Check the appropriate descriptioa and sp% Ify si7e,number of units and pertinent information.) <br /> FOOD PROGRArl(1600) <br /> ❑Restaurant: Seating Capacity Square Footage rood Handlers Course required: YES ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑\'ending Machines—Number of Units <br /> ❑ Retail Market—Square footage El will[Meat Market only El Multiple Departments El Prepackaged Goods Only <br /> ❑ Mobile Food Vchicle---Make Vchicle Type Color <br /> Registration 9 License"n Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser--Number of Container in Afuld-Bead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) r <br /> ❑ Hazardous Waste Generator-- Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Rceyclers(2217) <br /> Tiered 1'ernaitting Facility, ❑ Coaditioually Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-ByTlule Fixed Unit ❑ hemut-By-Rule Housebold Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and F(amts <br /> HOUSING PROGRAM(2400) <br /> ❑ IloteLrAlotel Number of Units ❑ Jail or Exempt Institution--Numbcr of Units <br /> Employee Ifousing(2700) Use Finpforc e IIousino/Labor Canrp Appfica(ion Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ EnAronmcntal Assessment ❑ UST-CAP Site ❑ Local IMV Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned MY Site ❑ non-NPL/SEP Cleanup Site ❑R'tWQCB Cleanup Site ❑ }rater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑fool ❑ Spa ❑ Out of Sen•ice Paouspa ❑ Natural Badiiag Arca <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Nfaximum number of birds ❑ Kennel <br /> TATTOO BODY PIE=RCING,PERMAtIENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Per3uanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License.# Capacity Vehicle# <br /> ❑ Pumper Yard ❑Fack_age Treatment Plant- ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Asir Site <br /> Waste Tire Facility ❑ Compost Facility ❑ Pro cess[Recycle Facility ❑ CIA.Landfill Site <br /> ❑ Refuse Vehicles—Numbcr of Units ❑ Dump_ters>20 cu yd —14umber of Units ❑ F.arnVRanch 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 /> PUBLIC+NATER SYSTEM PROGRP M(4600) (Ise Pff S F.111) I6-02-003 Rher j plica(ion 1-orrn <br /> li=.rr1[RG[NCY NOTIFICATto;t roR Tttts FACILITY ANC)IOR UROGRAM <br /> CONT,ICP PF1,S(.)N Day Ph Night Ph <br /> I'ROGILI)<tiF.L4:�iEI T y74-14? rr _— —T El Surcharge Fui -L��— ❑ Other FFE -- <br /> Irvsrrrrotr.x ❑ Food Ilaruller <br /> ❑ Clrxt..s_ 11\SL t i t? !',llt) ----- llate----- it rvolr`I-i. _ <br /> ❑ Ca;h i'r.tC`:;L[ r_:f — C_1.0:rII IIFFICF DatV <br />