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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MAST F:RFILE RECORD INFORMATION FORM <br />..'-`9'41 el-4 Program at Existing F4cilltt Pl-,... Jo ram rind New Facility <br />Facili - _ ID Pro ram Record <br />Facility Facility Address \ 71- \ -3" —5- '3 r'-;,, 0 X in_ _ _9_.ar-2-e_2S (pie. cn.„ cito nova-yr-tato description mid alledey elm mit§stitsoll and art riiikii in traban ) <br />Mobilo Food Prep Unit- Make Vehicle Type <br />Re.gistraton* LiCeriSe # <br />Temporary F ood Facility -Dales of operation from <br />Special Event --aztes of opoiation from <br />giAartY PACICa&A 42000) <br />Grad* A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Una <br /> <br />Hazardous Materials BUS iness Plan (1900) Number of chemicals: <br />0 Ca/ARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />0 Hazardous Waste Generator (2200)----->-Torrs Generated Per Year <br />0 Tiered Permiturig Facility —> 0 CA (2232) 0 CE (2233, 2234,""L-1..,5, 2237) 0 PR (2231) 0 P8R NNW (2236) 0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use USTA ON E) forms <br />0 Other CUPA Program <br />NOVSING PROGRAM (2400) <br />O Hotel/Motel —Number (.27urrteirse mofEUri <br />4s p <br />jl or Exempt Institution —Number of Units H <br />plovee Housing/Labor Cprop Aoolica tiaoln orm <br />KELY_MiAncti (2%0 ) UNDERGROUND INJECTION ONTRO‘ (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local NW Cleanup Site 0 NPUSEP Cleanup Site 0 UM Site <br />0 Abandoned HW Site 0 non-NPUSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />acorjamuss.Thiaoreal (3600) <br />Number of Pools/Spas at Factity 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />vECTVIR CONTROL PROGRAM (4000) <br />Poultry Farrn—Mwdmum number of birds <br />EMMENT <br />tIVED TATTOO BOGY PiERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Si43elUste34120122 <br />Body Art Fealty-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />SAN JOAOUIN COUNTY t./01410 WASTE PISciciRpe (4200) <br />0 Pumper VehicleReg:stration License IS . Capacity fag EntgagIMLL Purriper Yard 0 Pad <br /> <br />age Chemical Toilets —Number of UUnitskage Treatment Plant <br />sot.* siosTE PROGRAM (4400)• <br />0 Landfill 0 Transfer Station <br />0, Wast. Tire Facblity 0 Compost Facility <br />0 Refuse Vehicles recount.) <br />MEDICAL, WAIIIIIPS6RAM @sag) <br />01:1 PrrarimansfryerCSataretIon VArterinCary Clinic s p re <br /> SkIlled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br /> <br />0 Common Storage Facility 0 2- 10 0 11 -60 <br />EiffliegilfitIRELIMErapAQQam. (4800) Use EIVALED 4_....442001.__1011 Form <br />P CONTACT PERSON 3 F rrY QQMM <br />Day ph Noigh t Ph <br />Other FEE 0 Surcha7e F <br />0 Food Fiant-lre;"------ 1,0 2- 2.- to 2? / <br />2,81Ctle C' 1'177 <br /> INVOICE IS <br />ACCOUNTING 01 <br />MASTERFILE RECORO 04FOR4ATW0N Ilt144K <br />EVELeagageot 0600) <br />0 Restaurant Se..*ON Catutoty _ Square Footage . <br />0 Commission/ 0 Pry storage only 0 with Food Preparabco <br />O Retail Market---Square ?Ex-A/4w 0 wiMeat Market only <br />la Mobile Food vet/1KM -Make Vehicle Type <br />NN:straoon a License # <br />• <br />Food Handlers Course required: Tel 0 No 0 <br />OVendIng Mach Ines Number of Units <br />0 Multiple Oeparirnents PrepaCKEieeci Goods Only <br />CStickert11 11-• ic2 <br />Color <br /> Sacker <br />to 0 Ice Plant 0 Produce Stand to 0 CFO DADS <br />0 Ag/Cannery Waste Site 0 Sludge/Ash Site <br />process/Recycle aciIity 0 CIA Landfill Site <br />Durnpsters 20 Cu yd of Unftl) 0 Farm/Ranch Cleanup site <br />> 60 generators <br />k • 1 !.. • <br />PROGRAM ELEMENT <br />INSPECTOO <br />*ped(* <br />1)23,13 ?-eA t- IQ <br />PERMIT VALID <br />AMOUNT PAID <br />Reviewco ay Date