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SAN JOAQUIN COUNTY EWRONMENTAL HEALTH DIYISIO <br /> MASTERFILE RE90RD INFORMATION FORM LH 00 69 <br /> ❑New U.l m'{ <br /> Pro rat isxistn{ lracili O 0 I Y ('L []N <br /> r cw EH Proram and New haclUt <br /> •Patti{t .ADt � '�? r 1 . .v ,r�r�1��Z{14e,t'sN�t�G' R'!J,hVl�/a'•�,2 1fe '�•'r"ft h: t �, •a•,, • <br /> �` �. ,, t . .�.;,,,.,..;.Pro ram.`Rccord•:ID�'�;r y,K�4r t"i.'' �s �� .,:, , <br /> Facility Address O >SZ', <br /> (Please Check the appropriate description and specifyixc jiumbd of units and mrtincnt information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Scaling Capacity Square Footago Food l;audlers Courseul <br /> xcq •red: vas❑ No [] <br /> ❑ Columissaly ❑ Dry storage only ❑'with rood Preparation ❑Vending Machines—Numbcr of units <br /> ❑ Rct$ail Market----Square footage ❑ with Mcat Market only ❑ Multiple Dearlmcnls ❑ Prepackaged Goods Only <br /> ❑ Mobile hood Vehicle-----Make Vehicle Type Color_ <br /> Registration 0 License 11 Stickcr 0 <br /> ❑ Mobile Food Prep Unit--Makc Vehicle Type Color <br /> Registration 11 License II slicker 11 <br /> Q TePiporary hoed Facility-----Dates of operation from to 11 Ice Plaut <br /> ❑ Special EVent - 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-Head Unit <br /> CUPA ❑ state Facility Surcharge(2399) <br /> HAZARDOUS WAS'T'E PROGRAM(2200) <br /> ❑ hazardous Waste Generator-----------------------Tons Generated Pcr Ycar - <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CL) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Ruic Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)----Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A anti/l fvrmr <br /> HOUSING PROGRAM(2400) <br /> ❑ I-IotcUMotcl-------Numbcr of Units ❑Jail or Exempt Institution—Number of Units <br /> Lwlrloycc ldoualug(2700)Use t;nrnlnveC lforrrirrr/Gn For r+�nn.f,�d�.r,rio,r Forrn <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental AssCS3111e1{t ❑ UST-CAP Site ❑ Local 1IW Cleanup Site ❑ NPL/SEP Clcanup Site ❑ UIC Silc ' <br /> ❑ Abandoned kIW Site ❑ non-NPL/SEP Clcanup Site ❑RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number orPools/.Spas.at Facility ❑ Pool ❑Spa ❑ Out of Scrvicc Pool/Spa ❑ Natural Bathing Arca <br /> VECTOR CONTROL PROGRAM(4000) t <br /> ❑ Poultry.Irarm Maximum number of birdsV ' <br /> ❑ ICcnncl <br /> TATT'OO.'BODY PIERCING. PERMANENT COSMETIC PROGRAM(4100) } <br /> ❑ Tattooin (4121) ❑ Body Piercing(4120) ❑ Permancut Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) j <br /> ❑ Pumper Vehicic--Rcgislration if License ffCapacity ' Vehicle If <br /> ❑ Pumper Yard ❑ Package Treatment Plallt ❑ CI{enllcal Toilets-------Numbcr of Units <br /> SOLID WASTE PROGRAM(4400) <br />_ ❑ <br /> Landfill ❑ Transfcr�Station•' ❑Ag/Cannery Waste Site 05ldgc/Ash Silc <br /> ❑ Waste Tire Facility ❑ Compost Facility •❑ u <br /> Process/Recycle Facility u Landfill Site <br /> ❑ Refuse Vehicles--Numbcr of Bails ❑ Dumpsters>20 cu yd----Numbcr of Units <br /> ° Cann/Ranch Clcanul►Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑Small Generator ❑ Limited hauler <br /> ❑ Trans[cr Station ❑ Veterinary Clinic ❑ Common Storage Facility y---❑ 2.' 10-------❑ 11 -GO------❑>GO generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS r/10969 Blue Agga allow Form <br /> EMERGENCY NOTIFICATION FORTHIB FACILITY ANp/Oft PROGRAM <br /> CONTACT PERSON Day Ph <br /> ..•.. .af,t.,r,, k,. Night Ph <br /> I�ItOC1tAM ... ;EE;��+A' ( ,r °P"!❑!i�xnfty.•r'�7''? 1Fa,r r t <br /> + Surehartc Fxgrr' ')''` ` '❑ l <br /> INSPE�CTOlt ll. PCttM1r VALID � �'" � " ' "�•.h �. Other FEE• <br /> ,' ❑ rood Ilandlcr----------`` <br /> ❑ CbcckN <br /> ,—I INvo�Ctiff <br /> Cash .RhVI�WCI)IlY*' �,: t r 3. t •r,r, ,•: <br /> 4•'�! ACCOUNI7NG DPPICC''s' r' :Date <br /> L'lI 6C69 PINK FOItM.doc <br />