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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ' ' D MA.STERFII.E RECORD"INFORMATION FORM (� ❑ New EH Program atExistia Facl!itX ❑New EH Progm and New Facility SEP 06 2012 Facility ID rkRP,./c6� Program Record ID Facility Address _ )91 (A) A14, . x: ��.� 5 ?' ` — ENVIRONMENTALHEWN PERMff/SERVICES H (Please heck the appropriate descdption and specify see number of units and pertinent information.) !o2 / FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course re wired• . Y£s ❑ No 13 ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑ Vending Machines Number of Units ❑ Retail Market ---Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only D 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 a to ❑ Implant Q Special Event Dates of operation 'from to ❑"Produce Stand pAIRY PROGRAM (2000) C7 Grade A Dairy t3 Grade B Dairy ❑ Milk Dispenser Number of Containers in Multi -head Unit COPA 0 State Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200)' 1 ❑ hazardous Waste Generafor-- Tons Generated Per Year _ CI Recycle I Exempt System (2299) CI GRT Offsite handlers (2218) Q Silver Only (2222) ❑ Appliance Recyclers (2217) Tiered Permitting Facility Cl Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) ❑ Permit By Rule Fixed Unit ❑ Permit -By Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number ofAST UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use US'I'A and B forms HOUSING PROGRAM (2400) ❑ HoteVMotel Nutter of Units Cl Jail or Exennpt Institution Number of Units Employee Housiag (2700) Use FmpMoyei Housing1abor Camp -&Plication Fonn SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL.(3000) 3 Environmental Assessment ❑ UST -CAP Site Cl Local HW Cleanup Site • Cl NPLISEP Cleanup Site 13 UTC Site [I Abandoned IIw Site 13nou-NPLISEP Cleanup Site D RWQCB Cleanup Site ' ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (360o) Number of PoolslSpas at Facility - 13 Pool VECTOR.CONTROL PROGRAM (4000) 13 Poultry Farm Maximum number of birds _ ❑ Spa Q Out of Service Pool/Spa ❑ Natural Bathing'Area 13 Kennel ATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) Tattooing (4121) E3 Body Piercing (4120) ❑ Permanent Cosmetics (4122) 1IQULD WASTE PROGRAM (4200) Il Pumper Vehicle—Rogistration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant • ❑ C'hemicaI Toilets Number of Units SOLID WASTE PROGRAM (440'0) ❑ Landrdi ❑ Transfer Station ❑ Ag i Cannery waste Site ❑ Studge/Ash Site ❑ Waste Tire Facility E3 Compost FaeiIity ❑ Proeess/Recycle Facility ❑ CIA,I.andfill Site 0 Refuse Vehicles Number of Units ❑ Dumpsters > 20 cu yd Number of Units 17 FarmlRanch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care D Acute Care 13 Stilled Nursing ❑ Large Generator L7 Small Generator Cl Limited hauler 1:1 Transfer Station (3 Veterinary Clinic (3 Common Storage Facility --132.10 ------ ❑ 11- 60 ----17 > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) UsePWSEHD 46-02-003 BfaeAppficadan Form 1EmERGENCY NOTIFICATION FOR THIS FACILITY AmDfoR PROGRAiVI Unum a r*r v vrnty nom., Dl, Nioht Ph PROGRAM ELEMENTa1FEE ❑ Surcharge FEE''. Cl Other FEE INSPECTOR# wPERMITVALID . to El Food Handler 13 Check # AMOUNT PAID Date INVOICE # t 0 Cash REwEwFO-sy ACCOUNMO OFFICE Date Macule Record Yank