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07/13/2012 11:02 2098305045 UPS STORE 3968 PAGE 04 .E SA14 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New E Program at Existing Facility ❑New EH Program and New Facility LFa iii D Pro ram Record ID F cilit Address $2(o CA416A N111, frac-u C A a531G (PI ase c ieck the appropriate description and specify size,number of units and pertinent Information.) EQOD PR GRAM(1600) ❑ Resta rant: Seating Capacity Square Footage Food Handlers Course regulreA: Yes ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market----Square footage ❑with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobil a Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobil Food Prep Unit Make Vehicle Typo Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant Spec al Event Dates of operation from to ❑ Produce Stand p 1RY PI OGRA (2000) - *Grad !A-EmIry' .—' -`0 Graa`®B Dairy ❑ MTIk'Dlspenser-Number of'Containeriin Muni-Head Unit Cl PA ❑ State Facility Surcharge(2399) W RDOUS WASTE PROGRAM(2200) Hazardous Waste Generator----------Tons Generated Per Year ❑ Recycle/Exempt System(2299) CRT Offsite Handlers(2218) ------ ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) iered Permitting Facility---------------- ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use UST A and S forms H USIN PROGRAM(2400) Hote]Motel--Number of Units ❑ Jail or Exempt Institution----Number of Units EmployEmployc a Housing (2700) Use Emaloyee Housing/Labor Camp Application Form ITEM TION(2900) UN gBOROUND INJECTION CONTRQL(3000) Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWOC13 Cleanup S1te ❑Water Quality Remedlation Site CRE T1014AL HEALTH P GRAM(3600) Numbei of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area CTO CONTROL PROGRAM(4000) Pou try Farm-------Maximum number of birds 171 Kennel J&IT_00.BODY PIERGI G PERMANENT COSMETIC eRQGRAM,(4100) I$LTattoolng(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) i UiD A5TE P GRAM (4200) 11 Pury per VehicleReglstration# License# Capacity Vehicle# 13 Pun per Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units 91, LID WASTE PROGRAM(4400) Lan Ifill ❑ Transfer Station ❑Ag/Cannery Waste Sita ❑ Sludge/Ash Site Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site Ref joe Vehicles(o of units) ❑ Dumpsters>20 cu yd (#of Units) ❑ Farm/Ranch Cleanup Site - EDICj L WASTE eRQGRAM (4500) Prir iary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler Tra afar Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 011 -60 ❑ >60 generators PUBLIC WATERS TEM PROGRAM(4600) Use PWS EHD 46-02-403 Blue Aaplicatlon Form EMERGENCY NOTIFICATION FOR THIS I` CILITY AND/OR PROGRAM ONT CT PERSON Day Ph Night Ph ROG M ELEMENT ,- .,) % ` FEE ❑ Surcharge Fee ❑ Other FEE NSPEc OR#tPERMIT VALID to 13 Food Handler .ID4 4.Che k# AMOUNT PAID Date INVOICE# Cab REVIEWED BY ACCOUNTING OFFICE Date Received Time Jul, 13, 2012 10:58AM No. 0542 4-02-04 MASTERFILE RECORD INFORMATION PINK