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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART MU,,T <br /> 11iASTERFILE RECORD INFOR111AT1ON F0101 <br /> ❑New E I I Program at Existicility —_� ' `' Ell Program and New Facility_ <br /> Facilit ID CTD � ( ( � Prohrant Record ID (� �,�.�3 O <br /> Facility Address — 15OC-0 - <br /> (Please Check the appropriate description and specify s'v_e,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food handlers Course required: YES❑ NO ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ Y•ith Food Preparation ❑\'ending Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Markel only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--lltake Vehicle Type Color <br /> Registration 9 License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker 4 <br /> ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant <br /> ❑ Special Eveat —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Mill:Dispenser--Numbcr of Containers in Nfulti-Head Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) r <br /> ❑ Hazardous Waste Cknerator-- Tons Generated Per Year ❑ Recycle f ETempt System(2299) <br /> ❑ CRT Offsite Handlers(2219) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pernut-By-Itule Fixed Unit ❑ Perriut-By-Rule Household Hazardous Was(e <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numbcr ofAST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and R farms <br /> HOUSING PROGRAM(2400) <br /> ❑ IIotclAlotel Numbcr of Units ❑ Jail or E3:empt Institution—Number of Units <br /> EMployec Ifousing(2700) Use Employee jf0usine,/Lab,,Carrrp APplica(ian Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ EaAroarnental Assessment ❑ UST-CAF Site ❑ Local IfW Cleaoup Site ❑ NPLISEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned II`V Site ❑ nou-NPLlSEP Cleanup Site ❑RWQCB Cleanup Site ❑ Water Quality Remediation Site - <br /> RECREATIONAL tiEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Foot ❑ Spa ❑ Out of Senice Fool/Spa ❑ Natural Bathing Arca <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑I'oultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing.(4120) ❑ I'erTuaneat Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper VehicIc—RegisAmtion# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> WWaste Tire Facility ❑ Compost Facility ❑ Process(Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd —1-lumber of Units ❑ FarmfRanch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Stodge Facility---❑ 2- 10---❑ 11 -60---- ❑ 60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PH,;F11l) 16-02-003 Rbic.,fpplica(ioa Fc)l'rt1 <br /> ENIERGENCY NOTrrICArlo;r FOR iltls FACILITY ANDiOR PROGRAM <br /> CONTACT I ERSON Day Ph Night Ph <br /> I'Rocr?,+,�t l?LE�iF_I�T L 1'GF. —�_ ❑ Surci,argc Fe t, ❑ Other iFEE <br /> Irtsrrcroa.Y 06Q C-- I'r:t till '+IAtiD — to _ ❑ Food handler <br /> ❑ Clrxb-r 1TtC-i,;lrS',�it} ----- Dais----- 11rVO[CT:ii' - <br /> --/ <br /> 0 !A ; -pp_r U.l[C <br />