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SAN JOAQUIIN COUNTY IsNVfRONMENTAL HEALTH DEI'A '1'MERT <br /> MASTERFILE RECORD INFORMATION FOM — <br /> New EH Program at Existing Facility ❑llcvr EIl Prom and Nc w Facility_ <br /> Facility rD A tib 6 59 I'rcRrani Record ID I <br /> Facilit , Address 21�n SO E (U,�u n.a. . ESca�on <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(11500) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ NO ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ N-itll Food Preparation ❑Vending Machiacs—Number of Unils_ <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Good3 Only <br /> ❑ Mobile Food Velticle---Make_ Vehicle Type Color <br /> Registration ll License# Sticker It <br /> ❑ Mobile Food Prep Unit—Make Veliicie Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice flint <br /> ❑ Special Eyeat --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser--Numbcr of Containers in Multi-Ilead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) t <br /> ❑Ilazardous Waste Generator-- Toru Generated Per Year ❑ Recycle I Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) _ ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑ I'cmut-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and F forms <br /> ROUSING PROGRAM(2400) <br /> ❑ Ho(enlotel Numbcr of Units ❑ Jail or Exempt Institution--Number of Units <br /> Employee Ifousing(2700) Use Employee HousiriclEabor Carne Applica(iorr Fomi <br /> SITE P41TIGATION(2900) UNDERGROUND INJECTIOII CONTROL(3000) <br /> ❑ Environmea(al Assessment ❑ UST-CAP Site ❑ Local MV Cleanup Site• 11NPL/SEP Cleanup Site ElUIC Site <br /> ❑ Abandoned IINS'Site 11non-NPLISEP Cleanup Site 11RIVQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PooWSpas at Facility ❑ Pool ❑ Spa ❑ Out of Senice Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM(4 100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Perruaneat Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Pard ❑ Package Treatment Plant. ❑ Chemical Toilets hdumber of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag I Cannery Waste Site ❑ Sludge/Ash Site <br /> IA Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA,Laudfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dump,ters>20 cu yd —Number of Units ❑ 13"arm/R3ach Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Circ ❑ Acute Care 0 Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited llauler <br /> ❑ Transfer Station ❑ Veteriaary Clinic ❑ Common Storage Facility-----❑ 2 - 10 ❑ 11 -60---❑ >60 generators <br /> PUBLIC WATER SYSTEN1 PROGRAM(4600) (Ise I/I;S FWD 46'42-003 Blue Applica(ion Furrrt <br /> EPACRGEHCY 140TIFICATIOta FOR--ms FACILITY AND/OR PROGRAM <br /> CONTACT PFi:sOr� Day Ph Meta Ph <br /> 1'Rticrc;>,ntF.Lr;nlr-_Nr - ----- —� 1"LL _ -�� ❑ Surchargcl'l:t _'--- ❑ OtbcrFEe <br /> Ir+srecroR � I'LI t.nl lrrtLlu to _ ❑ Food handler --- <br /> ❑ <br /> ❑ C,,li !'_C'.'��_:'l;hL'.; '�.l�j ��.I. D n_COtI:TII;Glappl,'[ ��/ 11.1tC � ! �- --- <br />