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SAN JOAQUI C UNTY tNVIRONMENTAL HALTA HALTDEPARTMENT MA TERFILE RECORD INFORMATIC tFOF M I. PAYME ❑New EH PmatE IsU Fa ill ew H Pro ram and New Facili RECE/V p Program Rord I Facili ID 66 I NOV 18 2j,0 Facility Address 113 I . es II1-' S'free. � sqN A14 (Please check the appro nate descriptli�n and specify size,number f uni and ertinen informa !on.) ENVIIRONto COL N FOOD PROGRAM(1600) III I� HEALTH DEP R rA ❑ Restaurant: SeatingCa acity . I! Square Footage Food Handlers Course reauired: YES® Na ❑ Commissary ❑ Dry storage only Iii ❑ with Food Preparation ❑Vending Machine Number of Units ❑ Retail Market--Squ re to tage ❑ w/Meal Ma t only ❑ Multiple Depadmen s❑ Prepackaged Goods Only ❑ Mobile Food Vehicle)—Make ice— Vehi Type Color li Regis ratio # I H Lice :e# Sticker# ' ❑ Mobile Food Prep Uliit— take I Vehid Type 11 Color Regis ratio i# I LiCE se# Sticker# ❑ Temporary Food Fa IlityDates o operation from to �� ❑ Ice Plant❑ Produce.,"tan ❑ Special Event--Date of peration' m Ill ❑ CFO ❑A ❑ B DAIRY PROGRAM(2000) I! ❑ Grade A Dairy ❑ Grad I B Dairy 10111 dk Di enser-Number of Containers in Multi-Head Unit CUPA ❑ Hazardous Materiale Bus ness PIA(((1900) Number of chei ricals: ❑ CaIARP Program I ❑I rogram 1 Facility ❑ Program Facility ❑ Prograr 3 Facility ' ❑ Hazardous Waste G nen for(2200-->-Tons Generated r Yea ❑ Tiered Permitting F cili --> I ii❑CA(2232) ❑ CE(223 2234 2235,2237) ❑ PBR � '231) 11PBR HHW(223 ❑ Aboveground Storm le T nk Facili (AST)(2800) Number f AST 1 I El Underground Storax a Ta k Program(UST)(2300)Use UST A d B f rms ❑Other CUPA Progra,(t,. ! HOUSING PROGRAM(2400) ❑ Hotel/Motel---Number f Units ;� Jailor Exempt Institution—Number of Units Employee Housing(2700 USE Em to b Housin /Labor Cam A batIOAForm SITE MITIGATION(2900) I I OUNI I (3000) I ❑ Environmental Assessm nt ❑'UST-CAP Site E) Local H Cleanp Site ❑ NPUSEP leanup Site ❑ UIC sit 1:1 Abandoned HW Sitel ❑ noa-NPUSEP Cleanup! RWQI B Cleanup Site 0ater Quality Remediation its RECREATIONAL HEALTHIPRO 3RAM(3660) Number of Pools/Spas a�Fa lity _I 11 11 Pool ❑ Spa ❑�Out of Service Pool/Sp 11 Natural Bathing.Area VEC R CONTROL P RA (4000) ill ❑ Poultry Farts---Maxim m number of birds ❑ Kennel TATTOO PIERCING. N O (4100) ❑ Body ArtPractitionelIr Re (4110) 11! ❑ Mechanical DSPS Noti atio (4115) ❑ Body Art Ficlllty-Single Use(4120) ❑ Body Art Facility-Sterili tion(41 1) ❑ Body Art Temp Eve Co-o (4130) ❑ Body Art- amp Event Mobile Facility 413.1) + LIQUID WASTE OGRA I (42)0) ❑ Pumper Vehlcle Reg strat on# License# Capacity ! Vehice# 1 ❑ Pumper Yard ❑I 1 3ackage Treatment Plant Chemical Toilets--Number of Units OLID W S E PROGRA (44(0) I ❑ Landfill ❑ Transfer Station ❑ Ag/C nery aste Site ( ❑ Sludge/Ash Site ❑Waste Tire Facility Io❑ Compos` �Facility 11Proc s/Re cle Facility 13CIA Landfill Site❑ Refuse Vehicles la oUnits 13Dum ers>Janerator 1111cu yd to of units) ❑ Farm/Ranch Cleanup Site M(115 110) ❑ Primary Care C Ac to Care Skilled Nursing ❑ rge Small!Generator Limited Hauler ❑ Transfer Station ❑ Vett)rmary Clinic ❑ Common E rage Facility 112-10 ID 11 -60 ❑ >60 generators PUBLIC W TEMP RAM 460)Use PWS EHD 46-02.00 lue lication Form � ( E ERGENCY NOTIFICATION FOR T FACILITY AND/OR PROGRAM _ 4 CONTACT PERSON C r)D$ . 11. ra- ciyph OS'49($ if Ech M ELEMENT IFEE d� Sur hat FEE " Other FEE R# PERMITI,VALID I� ZO t0 �� 'O! Food Handler If MOUNTIPIAI ate �� AVOICE# 'n REVIEV(ED a 1 ACCOUNTING O ICE ate yEJ it./ 4/2313 - ( I J /1Z � I MA51tERFILE RECO DIN RMATION INKI V23H ( IJ1- 1