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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ID New EH Prozram at Existing Facility ❑New EH Program and New Facility Facility TD V*00 ( l.M_ Program Record ID yR-0 S3?U SI - Facility Address Z.A(0 A/RaGrE t✓�y ��'�kEo�c �A 95201 (Please Check the appropriate description and specify sizenumber of units and pertinent information) FOOD PROGRAM (1600) RECEIVED AUG 2 0 2009 SAN JOAQUINENVIROCOU HEALTH DEP.gENTA NT, ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yrsp( No ❑ ❑ Commissary ❑ Drystorage only ❑ with Food Preparation ❑Vendiag Machines —Number of Units ❑ Retail Market —Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑MobileFoodV Mobile cele—Makergrykocer $�2 Vehicle Type Par, Color �jrfr iC, 6N'P32f:2Y31SZ27 License #fFNOIrIG�rl MFU,_ Sticker# obile Food Prep Unit—Make Registration # ❑ Temporary Food Facility --Dates of operation from ❑ Special Event —Dates of operation from DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy Vehicle Type License # to _ Color Sticker # ❑ Ice Plant ❑ Produce Stand ❑ Milk Dispenser—Number of Containers in Multi -Head Unit CUPA ❑ State Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator- Tons Generated Per Year ❑ Recycle / Exempt System (2299) ❑ CRT Offsite Handlers (2219) ❑ 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 (AST) (2390) Number of AST . UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms HOUSING PROGRAM (2400) ❑ HotelfMotel —Number of Units ❑ Jail or Exempt Institution Number of Units Employee Housing (2700) Use Emploree HousinzUbor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) -❑ Environmeatal Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site. ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned IIW Site ❑ nou-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of PooWSpas at Facility ❑ Pool ❑ Spa 17 Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) - ❑ Poultry Farm—Maximum number of birds ❑ Kennel TATTOO 13ODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) - ❑ Tattooing (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle—Registration# License Capacity Vehicle# ❑ Pumper Yard . ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles —Number of Units ❑ Dumpsters> 20 cu yd —Number of Units ❑ FarmfRanch Cleanup Site MEDICAL WASTE PROGRAM (4500) Cl Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility -13 2 - 10 — ❑ 11 - 60 --❑ > 60 generators PU13LI C WATER SYSTEM PROGRAM (4600) Use PIPS EUD l6-02-003 Blue Application Fonn EMERGENCY HOTWICAT10N FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON77' C NS Day Ph 'o9 27-811'(oo Night Ph rZo9) 6Z3'07S PROGRANIELFNIENT I &3 FEE 03 -017 ❑ Surcharge FEE ❑ Other FEE INSPECTOR AE I�% PERMIT VALID 'D 2O O to �Z13(�� 1 ❑Food Handler ^ p Check# ; 4 AMOUNT PAID 1� 3' �� Date 120/ bq l�r INVOICE# 1 I2,3 Cash REVIEWED BY 324 ACCOUNTING OFFICE - Date (qt (6