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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Proqram at Existing Facility Wew, EH Program and New Facility RF�FMv,yT Facility ID Lfir�o2LLss� Program Record ID -rKOS`i/D /U I S,q JUJ Jg �� N Facility Address,6308, Pl�,rit, �vs Ko3G �1t7c�xary �¢ZyE,q�rt94 U,N X71 (Please check the appropriate description and specify size, number of units and pertinent information.) 'loppMtA,90y FOOD PROGRAM (1600) ARTMF� TY ❑ Restaurant: Seating Capacity _ Square Footage Food Handlers Course required: YES ❑ to ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units 51 Retail Market—Square footage i 5b ❑ with Meat Market only ❑ Multiple Departmentsl,51; Prepackaged Goods Only ❑ Mobile Food Vehicle–Make Vehicle Type Color Registration # License # Sticker # ❑ Mobile Food Prep Unit Make Vehicle Type Color Registration # License # Sticker # ❑ Temporary Food Facility –Dates of operation from to ❑ Ice Plant ❑ Special Event Dates of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dalry ❑ Grade B Dalry ❑ Milk Dispenser -Number of Containers in Mutti-Head Unit _ CUPA ❑ State Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator -----------Tons Generated Per Year ❑ RecyclelExempt System (2299) ❑ CRT Offsite Handlers (2218) ❑ 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) ❑ Hotel/Motel—Number of Units ❑ Jail or Exempt Institution —Number of Units Employee Housing (2700) Use Employee HousinW"borCamp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility -AE9-- ❑ Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm ---Maximum number of birds _ ❑ Spa TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (4121) ❑ Body Piercing (4120) LIQUID WASTE PROGRAM (4200) ❑ Out of Service Pool/Spa ❑ Natural Bathing Area ❑ Kennel ❑ Permanent Cosmetics (4122) ❑ 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 ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd (# of units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 -10 ❑ 11-60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02.003 Blue Application Form CONTACT PERSON dCW1191111 Day Ph Night Ph J M_" E PROGRAM ELEMENT FEE . 6D ❑ Surchagge F E ❑ Other FEE INSPECTOR# 35o PERMITVALID 7 t0 7/3 72" ❑ Food Handler ❑ Check # .5f AMOUNT PAID l D DateZ INVOICE # 35 41-0 gy ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date "7 i1S 48-02-034 MASTERFILE RECORD INFORMATION PINK 11/15/07