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- • SAN JOAQUIN COUNTY E RONMENTAL HEALTH DIVISION MASTERFILE RECORD INFORMATION FORM 031-100 69 New CH Pro nm at Lxisrl lrFacilityq< []New FH Pro ram and New FacilityDQ '�/) G ✓7/ .r••,+•' t ,�� . ',si�lr�^.L�X45 `al7i'MXa•� s•'Vf'W,4l1�vA'• 1'".tF'.:"'•+• q i.. : t. 1 1 1�O - / :•Jl aCll! ' '� �:,'. -l'ir Y.."-b• �'-• ,l1°list-}.q;$iFy+'kx I'ro i•airi'Rccord"ID y'• , Facility Address 3 !l � 'W S L-77 Zvi �4E?a (Please Chcck the appropriate description and ccif ixc number of units and icrtincn inf rmati n. p Y�--�-- 1 t o a ) FOOD PROGRAM(1600) ❑ Restaurant: Scaling Capacity S uarc Foota - .I 9 rood I�andlers Course c ui e r Yvs❑ No ❑ ❑ Conunissary ❑ Dry storage only ❑'with rood Preparation p ❑Needing Machines—Number of Units ❑ Retail Marltct----Square footage ❑ with Mcal Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile rood Vehicle-----Make Vchicic Type Color Registration II License II Stickcr II ❑ Mobile rood Prep Uait--Make Vehicle Type Color ' Registration 0 License a Stickcr/l Teluporary V99d Facility-----Dates of operation from to ❑ Ice dant ❑ Special Event - Dates of operation - from to ❑ Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy. 11 Grade II Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit CUPA ❑ State racflity Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) _ ❑ Ilaxai'dous Waste Generator-----------------------'Pons Generated Per Year Ticrcd Pcrmitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CC) ❑ Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANIC FACILITY(AST)(2390)---Numbcr of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use SISTA gird n forill HOUSING PROGRAM(2400) ❑ Ilotel/Motel-------Numbcr of Units []Jail or Exculpt Institution Numbcr of Units 'Linployce ilousing(2700)'Uve L�rrmlavcc HorroinrfGrt mr Crruu,A.,.licado r Form SITE MITIGATION(2900) UNDERGROUND INJECTIONCONTROL(3000) ❑ Environmental A33C53111Cnt ❑ UST-CAP Site ❑ Local hIW Cleanup Site : ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned I-IW Site ❑ non-NPL/SEP Clean up Site ❑RWQCB Cleanup Sit El Quality Rcmctliation Site . i , RECREATIONAL HEALTH PROGRAM(3600) ' Number of Pools/Spas.at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Arca VECTOR CONTROL PROGRAM(4000) ❑ roultiy rarnt Maximum number of birds ❑ Kennel TATTOO.'DODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooin�(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4 122) %-v LIQUID WASTE PROGRAM(4200) j ❑ Pumper Vehicle--Registration i/ License!f Capacity ❑ Pumper Yard P Y ' Vehicle N , ❑ Package Treatment Plant ❑ CllcIldcal Toilcts-------Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑Transfcr,Station ❑Ag/Cannery Waste site ❑SludgdAsh Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycic Facillty (y�j� ❑ Refuse Vehicles--Numbcr of units �t, kCIA Landfill Site r ❑ Dumpstcrs>20 cu yd----Numbcr of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) `J ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator . ❑Small Generator ❑ Limited Hauler ❑ Trausfer Station ❑ Veterinary Clinic 13 Common Storage Facility----❑2.' 1 o----»-❑ 11 -GO------❑>GO generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PIES C11000BIrrcAnnlrcatiattrorrn EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON /�/.Jf �1 Day Pit Night ph Itl3VIViMAi 1 Ir�.tMr5lNemaF A;'' ..N ---- '.� LEMENT , + �f Pfi IN 1' +JI M• �H '^ '' ❑$Ui CIIaCgC FP.��•+t'k, ❑ OtIle FEF:' s CCTOIt/f. PCItMIT VALID '• ° '4 1 w ❑ Chcck N AMOUNT X'AtU ' la t. Foo Handler 1 :-1 Cash :Rcvi�wr;d ay: x"».Y ,ltiN .+. ., k,. Date + + INVOICE# ACCOLWING C)PFICL't' ., `''' . •.,,...•. �• ,:;'. Date I'll W69 PINK FORM.doc