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SAN JOAQUIN COUNTY ENVIRONMENTAL 11EALTI1 DEPARTI TENT MASTERFILE RECORD I NFORMATION FORM R3 V ❑New EH Program at Existing Facility []New laH EE22=and New Facility } E B Q 2 2009 Facility ID Pry ram Record ID 2r X Facility Address _ c3 Y� /7�� ENVIRONMENT HEALTH '�lrl_C PERMIT/SERVICES (Please Check the appropriate description and specify E!Le,number of units and pertinent information) 170 OD PICOGRAM(1600) ❑Restaurant: Seating Capacity Square Footage: Food Handlers Course re wired:. YEs❑ No❑ ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market—Square footage ❑with Meat Market only ❑MuItiple Departments ❑Prepackaged Goods Only ❑ Mobile Food Vehicle-•---Make Vehicle Type Color Registration# License# Sticker# ❑Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# ❑Temporary Food Facility:Dates of operation from to ❑ Ice Plant ❑ Special Event —Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(2004) ❑ Grade A Dairy ❑Grade D Dairy ❑Mill:Dispenser Numbcr of Containers in Multi-Head Unit u CUPA ❑State Facility Surcharge(2399) IIAZARDOUS WASTE PROGRAM(.2200): t ❑Hazardous Waste Generafor. Tons Generated Per Year ❑Recycle/Exempt System(2299) ❑CRT Offsite Handlers(221s) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit By Rule Fixed Unit ❑Permit-By-Rule,Household Hazardous Waste ❑ABOVEGROUND STORAGE TANK FACILITY(AS')(2390) Number of AST .UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms HOUSING PROGRAM(2400) ❑HotellMotet Number of units .❑Jail or Exempt Institution Number of Units Eargloya Housing(2700)UseEntirloyee Housi►r /I�_abor Cam __ fiaatlon Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROV 000) ❑Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site ❑Abandoned RW Site ❑ aan-NPIJSEP Cleanup Site ❑RWQCII Cleanup Site ❑IVater Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑P901 ❑Spa ❑Out of Service Pooi/Spa ❑Natural Bathing Area VECTOIt.CONTROL PROGRAM(4000) ❑ Poultry Farrar Maximum number of birds ❑Kennel TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) Icne Capacity ZPumper Vehicle—Registration# 9PumperYard ❑Package Treatment Plant- l]Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) 3Z ❑ Landfill ❑Transfer Station ❑Ag 1 Cannery Waste Site ❑ SludgelAsh Site ❑Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA-Landfill Site ❑Refuse Vehicles--Number of Units ❑Dumpsfers>20 cu yd----Number of Units ❑FarmlRanch Cleanup Site MEDICAL WASTE PROGRAM(4500) © Primary Care ❑Acute Care ❑ SHIled.Nursing ❑Large Generator 0 Small Generator ❑Limited hauler ❑Transfer Station ©Veterinary Clinic ❑Common Storage Facility--O 2-10 ❑ 11-60-----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS E11D 46-02-403 Mae Application-Form l✓MERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR(PROGRAM CONTACT PERSON 7 Day Ph 6:�6 j - .' Night Ph PROGRAM ELEMENT '42,2 q,_ FEE [0•cT d ❑ Surcharge FEE ❑ Other FEE INSPECTOR# SIC`f L PERMIT VALID to ❑ Food Handler ❑ Check AMOUNT PAID _ Date INVOICP# ❑ Cash REVIEWED BY Civ f?�L ACCOUNTING OFFICE ` Date