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05iF18/2004 11: 10 454013e Erl%I/IPOJr,1ENTAL HEALTH PAGE 01 Amok SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART ENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Pro ,ram at Exi.stin Facility jS ❑New EH Program and New Facility _ll '' Facilit ID PdN�kE 62t�KFAs j Program Record IA SZ Z�3 /`I_I f U�1 r--,, Facility Address Ilol w `T-u2uE2 R_opfl (Please Chccic the appropriate description and specify size,number of unite and pertinent information.) FOOD PROGRAM(1000) ❑ Restaurani: Seating Capacity Square footage Food Handlers Course required: Yrs ❑ No ❑ ❑ Commissary ❑ Diy storage only ❑ with Food Preparation ❑Vending Machines--Number of Units ❑ Retail Market----Square rootage ❑ With MCat N13rkct only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Fond Vehicle-----Make Vehicle Type Color _ Registration # _ Licensc:# Sticker# ❑ Mobile Food Prep Unit--Make Vchicic Typc Color Registration 4 License# Sticlecr# ❑ Temporary Food Facility-----Dates of operation from to ❑ Ice Plant OSpccial Event --Dates of operation from -7I4IO4 1.0-21( � ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Millc Dispenser---NuTr.ber of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAi•i (2200) ❑ Hazardous Waste Generator------------Tons Generated Per Year —❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers (2213) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) Tiered Permitting Facility------------------ ❑ Conditionally Authonzcd(CA) ❑ Conditionally Exempt(CE) ❑ Permit-Jay-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACiLITV(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(LJST) PROGRAM (2300) Use UST A and B tbrms HOUSING PROGRAM(2400) ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Tnctitution-------Numbcr of Units . Employee Tiousing(2700) Use Emnlnyee FJousine/Labor Camp Application Form SITE MITIGATION(2900) UNDER©ROUND INJECTION CONTROL(3000) El Environmental Assessment ❑ UST-CAP Site ❑ Local iiw Cleanup Site ❑ NPL/SEP Cleanup Site ❑ L11C site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Numbcr or Poolc%Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm--------Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) El Body Piercing(4120) ❑ Permanent Cosmetics(d12z) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle--Registration# Liccnsc# Capacity Vehicle ❑ Pumper Yard ❑ Package Trentment Plant ❑ Chemical Toilets-------Numbcr of Units _ SOLID WASTE PROGRAM(4400) ❑ Landllll ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles--Numbcr of Units ❑ Dumpsters>20 cn yd ----Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ---❑ >GO generators El Transfer Station El Veterinary Clinic ❑ Common Storage Facility-----❑ 2- 10-------❑ 1 1 -h0-"- PUBLIC WATER SYSTEM PROGRAM(4600) Use PIVS EHD 46-02-003 fliuejpplicallon Form EmrRGENCY NOTIFICATION FOR TH18 FACILITY AND/OR PROGRAM CONTACT PERSON 0-44R-t5 I`>°It�FNLlc1`� DavPh , - 4(03"1 Night Ph_- yq�Z PROGRAM FuMENT� _ FEF � -D ❑ Surcharge FEE ❑ Other FEE INSPECTOR# O�LwL 1 PF,RMIT Vnf.ID 'q1 to C/ 11 ❑ Food Handier Q 1 1 Cbcck 4 { AMOUNT PAiD_ � 13 0Z) Date /ham[O 1 _�l /IuvOTCr� �a-8-!�--- ❑ Cash Rf.vIewPDBY ^CCOUNYINrt7rnt:L• c � �v . Datc Zvi 1C) MAstetfle Record Pirk 0-02-03a inac MAIN