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SAN, JOAQUIN COUNTY ENVIRONMENTAL HEALTH! DEPARTMENT <br /> MASTERFILEr RECORD 4NFORMIATION'FORM <br /> ❑New EH Program at Existing Facifty <br /> JaNew EH Program and New Faclirdy <br /> Facility 0 PMqrarn Record I0 2(e <br /> Faci'iity Address f-,a ne ikdale, q 1 <br /> (Please check the appropriate deacroprtlon and specify size nuaher,oT nn is and pettonent mfarmation,} <br /> FOOD PROGRAM(100) <br /> I]Resbtaurant: SeeEing Capacity® Square Fzoiage Food Handlers Course required! Yes No 12 <br /> 0 Commissaiy ®Dry storage only EJ vAth Food Pceperallon E3Vending MachlnallNumber of Units <br /> El Retail Market—Square footage ®vft Meas Market only ®Multiple BeparlmentsO Prepackaged Goads On!y <br /> ❑ Mobile Food Vehicle-Make Vehicle Type Calor <br /> Registration A License A Sucker* <br /> ❑ Mehl le wood Prep Unit Make 5}ehm*Type Cow <br /> Registraticn* License 3 Slicker* <br /> ❑Temporary Food Pecolity-Dales of operation from 10 ❑Ice Plant <br /> ❑':Special Event Dates of operation Von; to ❑ iPmduco Stand <br /> DA[HX PRQ9RAM (2m) r-Po C L P4--c$ A 127 <br /> El Grade A Dalry '❑ Grade®Oallry ❑ MfBk 6'lsponsor•Number of Conteinam In Mulli-Mad Unit_ <br /> COPA ❑' State Facillty Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Gencrator- -- Tarns Gene-ated Per Year (3 Roo)--1ofEreampt System 0999 <br /> EI CRT Onsite Handlers(2218) ---.-. ®Silver Only(2222) ❑Appltenee St"eni(2217) <br /> Tiered PentNlting Facility---- ❑ Conditionally Authorized (CA) ❑ CondiaonaSy Exempt(CE) <br /> ❑ PcrmibBrRUIQr Fixed Unit ❑ Pemtily®y-Rule.Household Hazardous Watto <br /> ❑ ABOVEGROUND STORAGE TANG(FACILATY(AST)(2350)' Number cfAST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM (2300) Use LIST/T amdS'_fbmra <br /> ".V8ING PROGRAM(24!00) - <br /> ❑. HotgilMotel—Number of Units ❑ Jail or Exempt Imstt'WYloit—Nurpbor of Units <br /> Employee Housing(2700)tlae Lmmtovoe M�ousL m barCww AonN'aagpE Fomr <br /> SITE MIT19811ON(2500) UNQMGR"Q tWEGTrC_N CONTROL(3090) <br /> ❑Environmental Assessment ® UST-CAP Site ❑ Local HW Cleanup site U NP'I tSEP Cleanup Site ❑ 'OIG Silas <br /> •Abandoned HW Site 13 non-NPL ISEP Cleanup Site C3RV=B Cleanup Site ClWater QualityRemediation Sfine <br /> RECRE&I]QUAL HEALTH PROfLRAM➢(3800) <br /> Number of Pools(Spas al Facility_ ❑Poel ❑ apo ❑Out of Service Poollspe ❑ Natural Bathing Argo <br /> VECFOR CONTROL PR,OGRA'M(4000) <br /> ❑Poultry FarrD---vMammum number of birds 0 Kennel <br /> TATTOO,GQQj PIERCING,PERMANENT C:0211 TrC PR©ARAM(Al 00) <br /> ❑Tattecing(4121) E3 Body Piercing(4120} E3 Permanent Cosmedes(4122) <br /> MQlil)WABTE PROGRAM(4200) <br /> EI'PumperVehicleRegisliationfi Lieemeol Csp :dOy Vohicle# <br /> C1 Pumper Yard 0 Paekngo Treatment Plant IQ Chemical Toilets—Number of Units <br /> SOLID VIVABTE i Eg_ggW(4400) <br /> '❑Landfill 13 Transfer Station ❑ AgfCannery Waste Site ❑SludgelAsh Site <br /> ❑Waste Tore Fmcitlty ❑Compost Faclility ❑iPmeessiRacycle Facility E7 CfA landfill site <br /> E3 Refuse Vehicles to duvw ❑ Dumpslers>20 eH yd to of urns, ❑FarmiRanch Cleanup Site <br /> MEMUL WAST1E.PROGRAM(4500) <br /> ❑Primary Care ❑Acute Care © Skilled Nutsirtg ❑ Large Generator ❑ Small Cariarator ❑ Limited Hauler <br /> ®Transfer station ❑Vemeifnary Clinic 17 Common Storage Facility ❑2- 10 1:3 11 •60 ❑>60_denerstom <br /> Pelelis;WATER&YSTRM PROGRAM(4600)We PWS END,46&Z-M.Btue AAp8caVdn FavP <br /> 'iEmERGENCY.gjWA710N EM TNIs EACILITiY ARmast PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PRoaitAm ELEMENT F OT ®6uMhaFger_qEE ❑¢lever FEE <br /> INSPECTORS R]SSS PERMIT VALID 0 a7 i5 to 16/31/ 0 Fooil Haf1de <br /> Ctieck 9 242E AmoUNT PAID 457/sy.ob gate 11 INVOICE m <br /> .ca5t1 RtrvzEv�isG=Y AcCn-u 9nmz OFFIc2 Date /43 <br /> 46-02-434 MASTERFILf REC:CRD INFORmA.-FkON?WK <br /> 11n�3 <br />