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SAN JOAQUIN COUNTY LNVIRONMENTAL HEALTH DIVISION MASTERFILE RECORD INFORMATION FORM MH 00 69 ❑New HH program at L4x!g!pg l:acilr D D 3J L/ []New EH Pro ram•nd New FacilityP/Q Q 7 r' ;•. .. yl „ , e ,n5• ,t dW 114 . ""'C'.;fl•;M5Y1Ni1'•F'; wqt l . 1 ti A rl ,dpi ►�'T'.MtL� Tf-P C ti+• .raClllt SID + .. i a ,� t r� �.;%• �' r 1l r :2r ��ii�i 'ka. ': a.F,; ' Facility Address b D -}- (Please Check the appropriate description and spccifylircr cumber of units and mertinent ii formation.) FOOD PROGRAM(1600) ❑ Restaurant: Scaling Capacity Squarc Footago , Food handlers Course c ui ❑ Commissary ❑ Dry storage only ❑'with rood Preparation v ❑ No❑ p ❑Vending Machines—Number of Units ❑ Reti;mll Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food VChICIe-----Make Vehicle Type or _ Registration q License# Slicker Coll ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration 11 License a Sticker 0 ❑ Temporary hood racility-----Dates of operation from ' to Ice Plant ❑ ❑Special Eveit - Dales of operation - from to 13 Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Numbcr of Containers in Multi-Head Unit CUP A ❑State racillty Surcharge(2399) 14AZARDOUS WASTE PROGRAM(2200) ❑ hazardous Waste Generator---------------------Tons Generated Pcr Ycar Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑Conditionally Exempt(CC) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule I'ouschold I-tacardous Waste ❑ ABOVEGROUND STORAGE TANK I!ACILITY(AST)(2390)----Numbcr of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)UseVST A and n forme HOUSING PROGRAM(2400) ❑ klotel/Motel-------Number of Units ❑Jail or Exempt Institution Numbcr of Units •/ I;utployce Housing(2700)Use Hirlyforee Horrcitr-frb C....... w....Uclilion Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Euvironmcutal AsSessinlCnt ❑ UST-CAP Site ❑ Local h1W Cleanup Site ❑NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ mon-NPLJSEP Cleanup Site. ❑RWQCI3 Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Numbcr of pools/,Spas.at Facilily ❑ Pool ❑.Spa ❑ Out of Service PooUSpa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM '(4000) ❑ Poultry,harm Maximum number of birds ❑ Kcancl TATTOO, BODY PIERCING. PERMANENT COSMETIC PROGRAM(4100) Y ❑ '1'attooin�(4121) ❑Body Piercing(4120) ❑ Permanent Cosnnc(lcs(4122) - LiQUID WASTE PROGRAM(4200) ❑ Pumper Vchicle--Registration 0 License If' Capacity Vchicic N 13 Pumper Yard ❑ Package Trcatmcnt Plaut ❑ Chemical Toilets-------Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ TransferStation. ❑Ag/Caancry Wastc Site ❑Slud ❑ Waste Tire Facility ❑ Com ost Facili gdAsh Site Compost Facility ❑ Proccss/Rccydc ractlttyiA Land(ili Site ❑ Rcfusc Vehicles--Numbcr of Units ❑ Dumpstcrs>20 cu yd---Numbcr of Units MEDICAL WASTE PROGRAM(4500) F!:n/Ranch Cleanup Site ❑ Primary.Care ❑Acute Care ❑Skilled Nursing ❑Large Generator . ❑Small Generator ❑ Limited i(auler ❑ Transfer.Station ❑ Veterinary Clinic ❑ Common Stora a Facility Y---❑2.' 10'------❑ 1 I -GO-----❑>GO generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PISBH0069Bing Annficcrfforr!•'orm t EMERGENCY NOTIFICATION FORTHiS CA t:ILITYANOfOR PROGRAM CONTACT PERSON Day ph Night Pit ,+ ,.• �•rw i�fMrM!'1�war n ---�-"-'---- PROGItAM'EL aCSyrctiaCgCl•'•?►+v��'•,tr'3'i�f r`rx' a�j"r .. A�il'. 1••p 4 "1 3 y ��r., 1 i ❑ Other11E'ji lmmcToit 0, PcttMIT VALiD 3 a t 1" • - 7� 1O , 13 Food I•Iandler 13 Check 0Aj 1 AMOUNT AID } :1 Cash ` `t Date 1 INVOtC131f W' �•• .�.��:>.RM,.•'At:cotnmNc Oat=lcn^' '. t: ail t,;u9 rPINKroliM.rtoC Date .