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• <br />SAN JOAQUIN COUNTY ENVIRONMENTAL I3LALTR DEPARTA3ENT <br />MASTERFiLE RECORD INFORMATION FORM <br />i klew FN Pron m at Existinz Facility _ ]' !° New Eli Progrtun and New Fadlit} <br />ffl9ffV1M <br />AUG 2.7 2012 <br />ENVIRONMENT ERMI/SERVICES HEALTH <br />Facility iD 1�✓I PD n�1aqj�,) Program Record ll) <br />Facility Address f° !V--c�_____.f a�/,. <br />(please Check the appropriate d and specify jkt, number of units and pertinent information.) <br />FOOA PROGRAM (1600) <br />0 Restaurant: Seating Capacity Square Footage Food handlers Course re aired: - YFs ❑ No 13 <br />❑ Commissary 0 Dry storage only 0 with Food Preparation 01'ending Maehiaes —Number ofUmts <br />0 Retail Market--Sgw•tre footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />0 Mobile Food Vehicle Make Yei►ickType Color <br />Registration # License # sticker # <br />0 Mobile Food Prep Unit—Make Veliicle Type Color <br />Registration # License # Sticker # <br />0 Temporary Food FacilityDates of Operation from to CI Ice Plant <br />Q Special Event —Dates of operation from to 0 Produce Stand <br />DAIRY PROGRAM (2000) = <br />E} Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA 0 State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200)' <br />0 <br />2200) - <br />EI hazardous Waste Generaior- Tons Generated Per Year • 0 Recycle I Exempt System (2299) <br />0 CRT Offsite Handlers (2218) El Silver Only (2222) ❑ Appliance Recyclers (2117) <br />Tiered Permitting Facility 0 Conditionally Authorized (CA) 0 Conditionally Exempt (CE) <br />0 Permit ByRule FixedUa 0 Permit By Rule Household Hazardous Waste <br />13 ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />. UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A cued $ forms <br />HOUSING PROGRAM (2400) <br />0 HoteUMotel ----Number of Units II 12H or Exempt Institution Number of Units <br />Employee Housiat (2700) Use EW*yee7:foasiap/iabor Camp APPReadow FvrM <br />SITE MITIGATION (2900) - UNDERGROUND INJECTION CONTROL(3000) <br />El EnvironmentatAssessment 0 UST -CAP Site - 0 Local HW Cleanup Site. 0 NPL/SEP Cleanup Site 0 UIC Site <br />EI Abandoned IIW Site 0 non-NPLIM Cleanup Site 0 R'%YQCB Cleanup Site 11 Water Quality Remediation Site <br />RECRFA'I CONAL HEALTH PROGRAM (3600) <br />Nurnba• of PooWpas at Facility . ❑Pool 0 Spa 0 Out of Service PooUSpa 0 Natant! Bathing Area <br />VECTOR.CONTROL PROGRAM (4000) <br />0 Poultry Farm Maximum number of birds El Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />Tattooing (4121) EI Body Piercing (4120} [3Permaneat Cosmetics (4122) <br />]LIQUID WASTE PROGRAM (4200) <br />0- Pumper Vebicle—Regiskation# 1.icease Capacity Vehicle•# <br />0 Pumper Yard 0 Package Treatment Plant. 0 Chemical Toilets—Number of Units <br />SOLID WASTE PROGRAM (4400) <br />0 Landfill 0 Transfer Station 0 Ag / Cannery Waste Site 0 Sludge/Ash Site <br />0 Waste Tire Facility 0 Compost Facility El ProctsslReryde Facility 0 CIALandfrll Site <br />❑ Refuse Vehicles --Number of Units 0 Dumpsters > 20 ur yd —Number of Units 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />0 Primary Care - 0 Acute Care 0 Stalled Nursing 13 Large Generator 0 Small Generator 11 Limited IIanler <br />13 Transfer Station 0 Veterinary Clinic 13 Common Storage Facility --E1 Z -10 0 11- 60 ----13 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) UsePKISESD,(6-02.003 BlueAppliaalion Form <br />EMERGENCY NOTIFICATION FORTNIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON . _ c%1 �i� Day Ph Night Ph <br />]PROGRAM ELEMENT h W FEE 0 Surcharge F> •. 0 Other FEE <br />INSPFkT(W # _ PERmrr VA1JD to 11 Food Handler <br />El Check # AMOUNT PA .. Date INVom # <br />[7 Cash REVIEwED3;Y AcCOWnNG Or�tce Date <br />Macterfile Record Pini: <br />