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SArN JOAQUIN COUNTY ENVIRONMENTAL HRALTkI DIVISION MASTERFILF RECORD INFORMATION FORM EH 00 69 W New EH program at Existing+ Facili ❑Ncw EH Pro ram and New hacdd ' �FaCtht ID " 4, tF p 17} Art' C4�M1A rb 1�rat 1�A'•�c. i.r ^w•. .`�a [7 1'( + kx Y,. r MEN 1 RccordlD • a "�• : t FW'GtIVEp . Facility Address _5)q3, L_)• „e. "Y- (A gie�ny' (Please Check the appropriate description and specify ixei�>)bcr ofunits and ner(i_nent information.) FEB U 2003 FOOD PROGRAM(1600) SAN JOAQUIN COUNTY AITHSFCES❑ Restaurant: ScatiugCapacity otaba Food Handlers Course rcauir WO MLpiSIpN uarcFo •r ❑ Comn+issary ❑ Dry storage only ❑'with hood Preparation ❑Vending Machines—Numbcr of Units ❑ Retail Marltct----Square footage ❑ Willi Mcat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vel+icle-----Make Vehicle Type Color_ .. Itcgistration II Liccnsc Il Sticker!I ❑ Nloblic Food Prep Uuit--Make VchicicTypc Color ! Registration II License 0 Sticker It Q 'I'cn+porary Food I'aeility-----Dates of operalion from to Ice Plant ❑ Special Event Dates of operation from to PA��6�wrluc�tand DAIRY PROGRAM(2000) RECEIVED Cradc A Dairy ❑ Cradc 12 Dairy ❑ Milk Dispenser---Numbcr of Containers in Multi-l-Iead Unit CUP A ❑ State Facility Surcharge(2399) FEB 6 2303 HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator------------------------Tons Generated Pcr Year -SAN JOAOUIN COUNTY Ticrcd Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally i n—, MENTAL HEALTH DMSION ❑ Permit-By-Rule Fixed Unit ❑ Pcrmit-By-Rule I-louschold Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)---Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)We_UST it and/l forms HOUSING PROGRAM(2400) ❑ I-iotcl/Motel-------Numbcr of Units ❑Jail or Exempt Institution Numbcr of Units Isuy+lnyee Idousiug(2700)UsC C.'%►tl/IoyCe/lorrri►rr/-n ger C'enu,.1n.J.�nN,.,,torn+ SITE MITIGATION(2900) UNDERGROUND INJECTION CONTRUL(3000) ❑ Environmculal A3SC3511+ent ❑ UST-CAP Site ❑ Local I3W Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned I-IW Site ❑ non-NPUSEP Cleanup site ❑RWQCB Cleanup Site ❑ Water Quality Iicmcdlalion Site 1 RECREATIONAL HEALTH PROGRAM(3600)' NumberorPools/Spas.at Facility ❑ Pool ❑Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Arca VECTOR CONTROL PROGRAM(4000) ❑ Poultry.Farin Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4106) ❑Tattooin (4121) ❑ Body Piercing(4120) ❑ Permanent Cosrne'tics(4122) ' LIQUID WASTE PROGRAM(4200) j ❑ Pumper Vchicic--Rcgistration N l License 11' Capacity Vchicic!/ • ❑ Pumper Yard t 13 Package Treatntcnt Plant ❑ Cltcluical Toilets-------Numbcr of Units *SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ ransfcr Station ❑Ag/Cannery Waste Site ❑Sludgc/Ash Site 13 Waste Tire Facility ompost Facility ❑ Process/Recycle Facility ❑ CIA Landfill ❑ Refuse Vcllidcs--Numbcr of Units Site ❑ Dumpsters>10 cu yd----Numbcr of Units ❑ Farn+/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator . ❑51"ai1 Generator ❑ Limited hauler ❑ Transfer Station ❑ VeterinaryClinic [3COnilnon Storage Facillly....❑ 2. 10-------❑ 11 -60-----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use P_WSEU0069111ac�innlrrafiorrForm ! // EMERGENCY NOTIFICATION FOR TNIs FACILITY AND/OR PROGRAM CONTACT PERSON—lour I P.�ejAsen .WNW- DayPh tz g -I �I Night Ph j � /�'�{�•- 7� 7 ' A ItOV�W �1' , 1 I.I •FI• IY'4'7 TM tlf�ltp 1411 { i1I A�LtiMIiNT II. r I�:A I'.li'iY�J t �iS M t hi•i.I i�l�t�f :rolMll�!.��tJi�n�J'.''A � r f �, 5urcllargc rxx: ❑ Other FI;E INs,•t:Cro,t/l. t)••. PcltMrrVnI.ID '• I s `•. � • r', .co• .R 1-yds.4 p .�❑ Food izandlcr Cheek N _ �I AMOUNT PAID ,, • Date INVOICE# Cash Rt;V11.WC1)OY:` t• SM;�'+. .•. ", •,.v..ry>Rai t ACCOIINTINGrOFPICC^...,X• I ,r... Ell W69 PINK FORM.doc Da