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04/05/2002 16:13 2094633 FIFTH FLOOR 0 PAGE 03 <br /> SAM JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> MASTBRFILE RECORD DrFORMATION F4R'vtEH 00 69) <br /> New EH ProMM at Exiling FacitiN C3Ncw EH prog=and New FacilltY <br /> Facility 1D Pro ram Record <br /> Facility Address 1721 6 Y4 Sc `4- � /)v i`i an�r e C 6L <br /> (Please Check the appropriate description and specify SIM number of un',g and g2dnent information.) <br /> F000 PROGRAM(1600) <br /> ❑Resrauraat+ Searing CapacitySquare Footage Food Handlers Courser i Yss 0 1V4 <br /> C3 Commissary ❑ Dry storage only ® with Food Pt ❑Vending Machines–Number of Units <br /> 13 Retail Morket—Square foolagc ❑ with only ®Multiple Ocparanarus ® gat Goffs Only <br /> ❑Mobile Food Vehicle---Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Mobile Food Prep Unit–Make Vehicle Type Col's <br /> Re;isttatlon# License# Sticker# <br /> C3 Temporary Food Facility---Dates of operation from to ® ice Plant <br /> ❑Special Event - Data of operation from to C3 Produce Sand <br /> RAlRY PR2126M(2000) <br /> ❑Grade A Dairy ❑ Grade B Dairy 0 MaDispeuser—Number of Containers in Multi-Had Unit <br /> gM ®State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM.('..200) <br /> ❑ Hazardous'Waste Generator Tom Gammied Per Year <br /> Tiered Permitting Facility ❑ Conditionally Autb d(CA) ❑ Conditio=HY Extnupt(CE) <br /> ®Peanit By-Rule Find Unit ®Permit-By-Rule Household Hazardous waste <br /> ❑ABOVEGROUND STORAGE TANK FActurY( (239o)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTd and B Dorms <br /> ISOU§ING PRUGRAM(2400) <br /> ® <br /> C3 Hatel/Motel------Number of Unix Jailor Exempt Institution--Numberof U>stts; <br /> Employee Housing(2 700)Use mntevee floe aei/l ,gt(amn dW&l&1 Forrtl <br /> 1TIRAZION(2400) UNDMIGROUNR MANCTIQUco_ NTitoL(3000) <br /> C1 Environmental ent ❑ [1ST-CAP Site V Cleanup Site <br /> E3 ivP[.rSEP up Sita ❑ ULC Stta <br /> ❑ Abandoned HW Site ❑ too-NPL/SEP Cleanup Site RWQCB Clcannp Site ❑Water Quality RAmedlatIOR Site <br /> RE&RUMONA&1JEALTH P11013 (3600) <br /> Number of Pools/Spas u Facility ❑ Pool C3 Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR CoNTRoL PROD M(4000) <br /> C3 Paul"Farm Maximum number of birds C3 °Ql <br /> Z TToo sooy,INCI, gg,I!I RnsMM coSe/F.rTlc PROGRAM(4100) <br /> ❑Tattooing(4121) ® Body Pie (4120) ❑ pergment Cosinatics(4122) <br /> L19WA IwItM PBg2 (420Q) <br /> [3-Pumper Vehicle–Registration# Li # Capacity Vehicle 0 <br /> ❑ Pumper Yard ❑ Packap Treatment Plant ❑Chemical Toilou—NLumber of units <br /> solaig gL4=P!Mg (4400) <br /> Lando ❑Transfer Station t Caaoery Waste Site ❑StudgdAsh Site <br /> ❑ Waste Tire ifa dilry ❑Compost F9cift ecycle Facility ❑ CIA Land011 Site <br /> ® RWU=Vehicles–Number of Units,_,® _, ❑Du >30 ca yd--Number of Units ❑ FarwAtuch Cleanup Site <br /> I gpicAh W Tfi PROGttAM(4500) <br /> ❑ Primary can ❑ Acute Care ❑Skilled Y g Gcoemtor Osman Generator ❑Linalud 11aaler <br /> ❑Transfer Station ❑ Veterinary Clinic ❑ Common for aoo Facility-❑2-t 0 ❑ 11-ao--❑'60 s rs; <br /> E!usUC&4, R SXEM!Zgg (4600)We AWS 8 tuo rlamGicarfoa Form <br /> A-MtCr�IoTttstax-nom Fort FAClLtTY artaJoR PROQRAM <br /> Qq <br /> CONTACT PERSON Q►1 i Day Pb 2j)4-476-Z 2 2 Night Ph i' –5J75 <br /> PROCRAw ELX FEE_ Surcharge F= ❑ otherFa - <br /> trtsRtx rort s PMUVaT VALID _ to ❑ <br /> C3 t� Food H:radier <br /> rc a AMOUNT PAW Daae INVOICE lF <br /> ❑cash Rw4mww sy ACCO Date <br />