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/ <br /> "?SCSI <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> _ MASTERFILE RECORD INFORMATION FORM — I AN SAN �?4 2015 <br /> fleet EH Procram a1 Existing Facility ON -_HF :am and Ne­ Facllil Elg'l4OAQU�' <br /> ILASI tY ID _ 0023Program Record ID /L0 Z) 7h- fAT M1' <br /> Facility Address 11C-0 �e!,T <br /> (Pieeae chcrh the appmpdeie de5cdp6jen end specify alio number of union and cortinent Information.) <br /> F000 PROGi3A510600) <br /> O Reslawanh Seating CaVecily 13 uo.e Footace- Food Handlar2Couraa reeJuirau: •rsffi No O <br /> .Commissary ODry storage orly K Kohn Food Preparehon UVonding PAa0nin4RNurnber of Unilx <br /> ❑Retail Market....Square footage 0 Vdideet Market CMM 0 Mpitl;le OcPnments❑Plapackagac Gacn9 Only <br /> g Mobile Fpod Vahicie--idake /r -3,) !chide T pe + Color `.c <br /> : y _ - <br /> Registradcni Ucanse. n � L/. Stiriarx <br /> •Mobile Food Prop Unit..Make VaNde Type -_ Color <br /> Regisbatonk License# slicker <br /> ❑Temporary Food Facility-Dates of operation from ;c OT <br /> 0 Ice Plant O Produce Stand <br /> O Special Event--Dates of accretion from_, to O CFO 0 A 0 B <br /> DAIRY PROGRAM(2000) <br /> O Grade A Dairy O Grade 8 Dalry 0 Milk Dispenser-`lumber of Containelu in MUfl-lieed Unit_ <br /> CUPS <br /> 0 Hazardous Materials Business Plan(19GO) Number of chemicals: __ <br /> 0 CaIARP Program Cl Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br /> •Hazardous Waste Generator(2200)-------> Tons Cenented Per Year <br /> O Tiered Pemltting Facility----> OCA(2232) OCE(2233,2234,2235.2237) O PBR(2231) O FBR HHW(2236) <br /> O Aboveground Storage Tank Facility(AST)(2600) Number of ASTs <br /> 0 Underground Storage Tank Program(UST)(2300)Use USIA and E forms <br /> O Other CUPA Program <br /> HOUSING PROGRAM(2400) I 1 <br /> ❑HCtollMou,l----Numberof Unita O Jail or Exempt Institution----Number of Units _ <br /> Employee Hcusing12700)Lisa F I ee HouslnaR a her Camp Aeol/cefion Fore <br /> SITE MITIGATION(2900) UNOERCq9UND ItJrCTION CONTROI (3000) <br /> O Environmental Assessment O UST-CAP Site 0 Local 4W Cleanup Site O NPLISEP Cleanup Site 0 UIC Sita <br /> ❑Abandoned HW Site 0 non-NPLISEP Cleanup Site O RWQCS Cleanup Site O Water Ouality Remediation Site <br /> RECREA T104AL HEAL tH PROGRAM(3603) <br /> Numborof POo1s1Spasal Facility_ Cl Poul ❑Spa 0Oute:5e1vlce POOI!5pa O Natural Bathing Area <br /> VPCTORCONTROL PROGRAM(4000) <br /> 0 Poultry Farm----Maximum number of olyds ❑Kernel <br /> TATTCO GOOY PIERCING FRRNIANeMT COS1E11C PROGRAM(4100) <br /> 0 Body An Practitioner Reg(4110) 0 Mechanical DSPS Notification(411.5) 0 Body Art Facility-Single Use(412% <br /> 0 Body Art Facility-Sterilization(4121) O Body Art Temp Event Co-ord(4130) O Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> 0 Pumper VehicleFegistrallon Or. Licensees Capadry Vemcle W <br /> ❑Pumper Yard O Package Treatment Plant OChemical Toilets---Nurcbcr of Units <br /> 501_10 WA57E PROGRAM(4400) <br /> ❑Landfill O Transfer Station O AglCann¢ry'iyaste Site O SludgelAeh Site <br /> O Waste Tire Facility O Compost Facility O Frccess/Recycle Facility 0 CIA Landfill Site <br /> - O Refuse Vehicles(.-e.Ua ton)_ ❑Competent>20 on yd led U^tnl_^. O FamfRanch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> O Primary Care O Acute Care 0 S8lllod Nursing O Large Generator L Small Generator 0 Limited Hauler <br /> O Transfer StaOon O Veterinary Clinic O Common Stange Facility 172-10 011.60 O>SD gencaton; <br /> pI n iewATER SYSTEM PROGRAM(4EGO)Use PWS EHO 46.02_003 Elue ADclicarlaR FOMP <br /> E1,EReEICY. TiC i10N Fp4TKa FACILtTYANo/o PGODRAM <br /> CONTACT PERSON�,1 _q}e`l`�— Day Ph ILG-0(a/tx(7� Night Ph <br /> PROGRAM ELEMEN'r FEE 0 Surchar a FE 0 Other FEE <br /> INEoxctoaa 4 PEP.NITVALIO 2 / '^ _ 3/ S 0Food Handler <br /> 'pI / 0 .�� 6 Q. INVOICEx r /� <br /> 0 Chest n A.�G1f1I�IT-PAID Z Da:'- b <br /> O Cash _- R6Vr_WsO sr Ac_couren::SOFFIC Dal'- <br /> JE.C2d]< G45TERM FlE.C�nIYiNFORNATIOA PIAx <br /> 12''13 <br />