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a 7 <br /> SAN JOAQUIN COUNTY ENVtONR LNTAL HEALTH DEPARTMENT <br /> T�IASTERMLR RECORD INFORMATION FORM <br /> Mew EH and Nese Fadq <br /> ❑New EH Proat Existing Facility � <br /> Facilit ID ProwamRecordlD <br /> )e <br /> Facility Address 95-20'7 <br /> (Plt ase Check the appmpriatt dfsaiiption and specify Oz.cumber of units turd mdintnt futormatioa) <br /> FOOD IsROGR&M(1600) " <br /> O RaUurant• Seating C paetity Square Foett�ge Food Handlers Courser aired•• Yas C] No C3 ' <br /> ❑Feud' Na&Les-Number of Units <br /> Coraautl;`tary L1 Dry�tarage only' E3 with Food Prepn�tG xag . <br /> '❑Retail'IVlarket--Square;footage ©wiry Meat Market only. ❑Multiple its (3 Ptepacl aged Goods Only <br /> ❑Mobile F"d Vehicle--make Vehicie Type Color <br /> Registration# License# Sticker# <br /> ❑Mobtie Food Prep Unit-M*0 vel"elypo CID10f <br /> Registration# License# Sticker# <br /> O Temporary Food Facgfty—Oatcs of operation Um to � t7 Ice Plant <br /> ❑Special Event :Dates of ope mUon from to El-Produce Stand <br /> DAIRY PROGRAM(2M) <br /> 13 Grade A Dairy 13 Grade B Dairy ❑Me9k Dispenser--Number of Gmtakers is Multi-Head LIOR <br /> num 13 state Fadfity surdtarge(2399) <br /> IU ARDOUSWASTEPROGRAM(2209) I <br /> 13 Hazardous,%vaste Ceaierator- Tons Gated Per Year [3 Recycle IExempt System(2299) <br /> E3CRT OM*Handlers(22 1 s) 13 Save'Only q=) ;` [3 A�pliiance Recyclers(2W) <br /> Tiered re, sitting) ac hy- [3 Conditionally Authorized(CA) 0 Conditionally Exempt(CE) <br /> 13 Peamit By4WeFixcdUnit C1 Permit:By-tnkHousehold Aazu&us Waste . <br /> ABOVEGROUND STORAGE TANK FACIA=(AM(2390) Nwnber of AST <br /> UNDERGROUM STORAGE TANK(UST)PROGRAM(2340)Use=STA and B to*s- <br /> HOUSING i+ROGum(2444) k <br /> ❑Hotetiviotel NumberofUnits D Jail orExtwptbwfiitationof Units ------ <br /> Eaydoyee Rousing{27QO)U ayee l ousin lLabur aetxdnottaat mForm <br /> SITE MtTIGATION(x900) UNDtcRG1tOUND CNJEG170N CON7'R-W000) <br /> E3 Environmental Assessment d UST-Ce Site 13 Y.oail`MV Cleanup Site, 13 N un?Cleanup Site 13 UIC Site <br /> 13 Abandoned HW site ©noir-NPLMP Cleanup Site 0 RWQGB Cleanup Site 13Water Quality Remediation Site <br /> �;` RECR�lITIONAt HEALTH PROGRAM(3600} <br /> Nurnbar of Po01SMpas at F==it'y. 13 Pool Ci Spa Cf Girt of Somce,P"vSp3 ❑Nataral Bathing Area <br /> VECTOR.60HTROL PROGRAM(4000) <br /> 13 Poultry Farina Maximum numibcr of birds ©Kwan <br /> TAITOO,800YP1 CING PERMARMff COSMETIC PMGItAM(4100) <br /> Tattooing(4121) 13 Body Piercing(4120) C]Pere=tut Cossmeticc(4122) <br /> LIQUID wAM PRegnW(4200) <br /> El Pauper Ve 4ick-Rogitttation# -__-"---•-- License# capacity vehicle-# <br /> ❑Pamper Yard 11 Patlage Treatment that. D Chtwical Toiletx Nwx*a of Units <br /> SOLID 7UAS-M PROGRAM(4404) <br /> 13 Landfill 13 Traneer Station ❑A=1 Cammery Waste Site ❑Sludge/Ash Site <br /> Ll Waste Tut Fats ft 13 Compost Facility ❑Pr+o"WRecyde Facility [3 CLkj udfdi Site <br /> []Refuse v, dd des Number ofUnits Cl Du vdas>20 rn yd---Nuniba of Units 13 Fmo tanch Cleanup Site <br /> MEI/ICAL WAM PROGRAM(4500) A YT <br /> 13 Primary Circ 13 Acute Cate 13 Sisted Nursing Cl Lente Generator D Small Generator 13 <br /> i3 <br /> 13 Tnat cr Station 13 Veterinary Clinic ❑Conmon Storage Facft ❑2.10 ❑11-60 gY <br /> PUBLIC WATER SYSTKM PROC;RAM(4b00}Use.�P BA7)4eF0?-003 Blore AoplFarttax Fame JAN 0 J5 <br /> CHmoomy" '"-FICATIO11 FOIt7MS FACILITY AHWoR PROGRAM SAN JOAQUIN COUNTY <br /> CONTAC'rPERSON gDayph 2a0-2yI 1Lt�n Night Ph 1Fl <br /> PROGRAM ELt Nr u rt D FI�:Iy 01 ' 13 snrcha eras-•• ©Other Ftp AH I NiENT <br /> ' Irisrecrexa# 1�4.► PER MVAIJO . +' �l 15 to �P 3oi/I S 13 Food Sawdlera <br /> 13(heck# AMOUNT PMP �' 2S•v Date +(SI r S INVOICE#� -t' O <br /> Cast( REi�•e�r a�OMca D to "/5' <br /> Masterfile Record Pink <br />