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SAN JOAQUIN COUNTY ENMRONMENTAL HEALTH DIVISION <br /> MAST'ERFII,E RECORD INFORMATION FORM EH 00 69 <br /> N w 131-1 --- <br /> Proram at Existing racili 00•6 / '?- ❑New EH Pro ram and Ne l'acilit <br /> t ITIh Iael►rt IDF .nt Artt ,M141V ' 1rtiM, SPro"tr'W:rSYl4ln?IRA.e co1.Cn•diw.I5.D'l <br /> P o <br /> Facility Address � <br /> (Please Check the appropriate description and specify ize Immber or "all and ncrlincnt information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Stating Capacity S uare Foola o 1 5 •� <br /> q g food Handlers Course c ui c Yvs❑ No 11 <br /> ❑ Commissary ❑ Drystorage only ❑'•with rood Preparation []vending Machines—Numbcr of Units <br /> ❑ RetP Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile rood Vehicle-----Make VchicIc Typo Color_ <br /> Registration 11 License!l Sticker 0 <br /> ❑ IvIobiie Food Prep Uuit--Make Vehicle Type Color <br /> Registration 0 License 9 Slicker 0 <br /> 0 Temporary Food I:acility-----Dates of operation from ' to 13 Ice Plant <br /> ❑ Special Event - Dates of operation ' from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Cradc A Dairy. ❑ Cradc II Dairy ❑ Milk Dispenser---Number of Containers in Multi-licad Unit <br /> CUP A ❑ State rac'iilly Surcharge(2399) <br /> I-IAGARDOUs WASTE PROGRAM(2200) _ <br /> ❑ Hazardous Waste Generator-----------------------Tons Generated Pcr Ycar <br /> T►crcd Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixcd Unit ❑ Pcrmit-I3y-Ru►c I-touschold Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)----Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use_UST 11 one!n ferrlrs r <br /> HOUSING PROGRAM(2400) <br /> ❑ Ilotel/Motel-------Number of Units ❑Jail or Exempt Institution Number of units <br /> Employee liousing(2700)Use C.'m»lopec/forlsinC/!_tiGor Ganru Ayy-f adan rorm <br /> S ITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL 3000) <br /> ❑ Environmental Assessment, ❑ UST-CAP Site ❑ Local IIW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC site <br /> ❑ Abandoned I-IW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCD Cleanup Sit <br /> I c 13Water Quality Iiemcdiallon 5ilc <br /> RECREATIONAL HEALTH PROGRAM(3600)' • <br /> NumbcrorPools/Spas.at Facility [:] pool ❑Spa ❑ Out of service PooVSpa ❑ Natural Bathing Arca <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO.-BODY-PIERCING, PERMANENT COSMETIC PROGRAM(4 100) } <br /> ❑ Tattoeln (4121) ❑ Dody Picrclug(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) j <br /> ❑ Pumper Vehicle--Registration fE License/E' Capacity Vehicle N <br /> ❑ Pumper Yard 1 ❑ Package Treatmcut Plant ❑ Chcrulcal Toilets--.----Numbcr of Units ` <br /> SOLID WASTE PROGRAM(4400) J <br />_ ❑ <br /> Landfill ❑Transfcr,Station ❑Ag/Cannery Waste Site ❑Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility � CiA Landfill Site <br /> ❑ <br /> Refuse Vclridcs--Number of Units ❑ Dumpstcrs>20 cu yd----Numbcr of Units 1 <br /> • ❑ farm/Ranch Cleanup Sile <br /> MEDICAL WASTE PROGRAM(4500) ' • <br /> ❑ Primary Care ❑ Acute Care ❑Skiilcd Nursing 13 Large Generator . 13Slnall Generator C1 Limited Hauler <br /> ❑ Trausfcr Station ❑ Veterinary Clinic ❑ Common Stora Facility acilit <br /> g. • y-—❑ 2.I0-------❑ 11 -60------❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS Fornr <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON . <br /> • Day Ph Night Ph ' <br /> • j .pJF14 t! ,nr n y <br /> ritOCILA'm" -EMENT ° •I If E�rr+� !'1 . it "J <br /> ----- ❑5urclrar cl+rg <br /> rs ` ❑ Other FEE <br /> INSPCC 1 Ort ll. 5 I "I l0' <br /> PEIZMI'fVALID '' ❑ Food klandlcr <br /> ❑Check N f " <br /> AMOUNT PAID` Dale / INVOIC[s/l <br /> :1 Cash Rl:vl awti0 DY. 1 w r i r ,� o <br /> • •�r 'aai°,.`ACCOt1NTtN0C�PPICLT":.. . , ..a:_ Date <br /> El W69 PINK FORM.doc <br />